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A    TREATISE 


ON  COMMON  FORMS  OF 


Functional  Nervous  Diseases 


BY 


L.    PUTZEL,  M.D., 


PUysician  to  the  Clinic  for  Nervous  Diseases,  Belletue  Hospital   Out-Door  Department ; 
Visiting  Physician  for  Nervoxis  Diseases,  RandalTs  Island  Hospital  ; 
Pathologist  to  the  Lunatic  Asylum,  B.  I. ;  Curator 
to   Charity  Hospital,   etc. 


NEW    YORK: 
WILLIAM   WOOD    &    COMPANY^ 

27   Geeat  Jones  Street. 
1880. 


COPYEIGHT,    1880,    BT 

•WILLIAM    WOOB   &  COMPANY. 


Trow's 

Printing  and  Bookbinding  Company, 

20X-2I3  East  \7.tk  Street, 

NEW   YORK. 


PROF.   E.  G.  JANEWAY,  M.D., 

IN    APPRECIATION     OF    HIS    UNSURPASSED    ABILITY     AS     A     DIAGNOSTICIAN     AND     CLINICAL 

TEACHER,    AJTD    AS   A    SLIGHT    TOKEN   OF    GRATITUDE   FOR    THE   INSTRUCTION 

RECEIVED     DURING    A    NUMBER     OF     TEARS    OF     PROFESSIONAL 

INTERCOURSE,     THIS    BOOK     IS     RESPECTFULLY 

BY  THE  AUTHOR. 


PEEFAOE. 


Pathological  anatomy  has  exercised  such  an  enormous  influence 
upon  the  advances  made  in  practical  medicine  within  the  last  twenty- 
five  years  that  many  pathologists  sneer  at  the  term  "  functional  "  dis- 
ease and  deny  its  very  existence. 

While  we  fully  agree  that  there  can  be  no  morbid  manifestations 
without  a  change  in  the  material  structure  of  the  organs  involved,  we 
are  nevertheless  fully  convinced,  in  view  of  the  fruitless  search  of 
pathological  anatomists,  that  the  diseases  which  we  have  considered  in 
this  work  present  no  primary  anatomical  changes  which  are  visible  to 
the  naked  eye  or  to  the  microscope — in  other  words,  that  the  changes 
in  structure  are  of  a  molecular  nature. 

Perhaps  in  the  reviving  growth  of  physiological  chemistry,  the  ba- 
lance of  the  chemist  will  determine  the  presence  of  subtle  changes  in 
the  constitution  of  the  diseased  organs,  and  will  afford  us  some  insight 
into  the  true  pathogeny  of  these  affections. 

The  tendency  to  the  disbelief  in  the  actual  existence  of  functional 
nervous  diseases  led  to  the  inconvenience  that  their  clinical  study  has 
been  neglected. 

If  we  glance  through  the  most  widely  known  text-books  on  ner- 
vous diseases  which  have  appeared  in  the  English  language,  we  will 
find  that  due  attention  is  not  paid  to  functional  affections,  although 
practically  they  are  by  far  the  most  important,  and  are  much  more 
frequently  encountered  by  physicians  than  diseases  due  to  organic 
lesions.  A  change  is  now,  however,  becoming  noticeable  in  this  re- 
spect, especially  in  foreign  literature. 

In  the  present  work  special  attention  has  been  paid  to  the  sections 
on  clinical  history  and  diagnosis,  as  it  is  especially  in  the  latter  respect 
that  mistakes  are  made.  I  have  entered  into  the  pathology  of  the 
affections  merely  with  the  view  of  giving  the  present  status  of  our  ac- 
tual knowledge  of  the  subject,  and  not  for  the  discussion  of  disputed 
questions. 

The  consideration  of  hysteria  has  been  omitted  because  this  dis- 


VI  PREFACE. 

ease  has  been  described  in  sufficient  detail  in  numerous  works  which 
are  now  in  the  hands  of  the  medical  public.  It  is  true  that  the 
French  school  have  recently  revealed  some  startling  and  hitherto 
undescribed  manifestations  of  hysteria,  which  they  have  included 
under  the  term  hystero-epilepsy,  and  which  have  excited  a  great  deal 
of  interest  in  scientific  circles.  In  our  own  country,  however,  these 
symptoms  are  observed  so  rarely  that  I  have  not  considered  myself 
justified  in  entering  into  the  subject  in  a  work  of  this  character. 

Some  of  the  forms  of  peripheral  paralysis  which  have  been  con- 
sidered in  the  final  article  cannot  be  regarded,  properly  speaking,  as 
functional,  but  I  have  discussed  them  under  that  heading  in  accord- 
ance with  long-established  custom  and  for  the  sake  of  completeness. 

In  conclusion,  I  desire  to  acknowledge  my  great  indebtedness  to 
my  friends  Drs.  V.  P.  Gibney,  R.  Yan  Santvoord,  and  S.  Heming- 
way, for  much  valuable  assistance  received  in  the  preparation  of  this 
work. 

L.  PUTZEL. 

252  East  Fokty-eighth  Street, 
New  York,  July  20,  1880. 


C  H  O  EE  A. 


CHAPTER  L 

CLINICAL    HISTORY. 


Chorea  is  essentially  a  disease  of  childhood,  though  it  occasionally 
begins  in  adult  life,  and,  in  rare  instances,  makes  its  appearance  in  old 
ao-e.  Its  first  beginnings  in  children  are  frequently  misinterpreted  as  the 
results  of  wilfulness.  A  child,  while  attending  school,  is  noticed  to  become 
restless  and  frequently  move  from  side  to  side  in  his  seat.  Twitchings 
of  the  muscles  of  the  hands  also  develop  and  are  evidenced  by  irregularity 
in  writing,  in  the  manner  of  holding  a  pen  or  pencil,  and  by  the  fact  that 
the  patient  will  drop  his  slate  or  some  other  light  object  more  frequently 
than  his  fellows.  In  addition,  certain  slight  manifestations  of  mental  dis- 
order make  their  appearance  at  the  same  time  as  the  development  of 
the  muscular  phenomena,  or  may  even  precede  the  latter.  These  symp- 
toms consist  of  slight  loss  of  memory,  and  inability  of  the  patients  to 
apply  themselves  to  their  studies  as  well  and  continuously  as  formerly. 
Children  who  were  previously  of  an  obedient  and  mild  disposition  become 
irritable,  obstinate  and  perverse.  They  become  insubordinate,  lose  their 
love  of  play,  and  are  not  so  affectionate  as  was  their  wont.  These  phe- 
nomena are  naturally  looked  upon  as  indubitable  evidences  of  wilfulness 
and  are  punished  accordingly,  thus  frequently  precipitating  and  aggra- 
vating the  course  of  the  disease.  The  muscular  symptoms  gradually 
spread  in  intensity  and  extent,  and  usually  attain  their  maximum  severity 
in  the  course  of  a  couple  of  weeks  to  a  month.  At  the  height  of  the  dis- 
ease, all  the  voluntary  muscles  in  the  body,  especially  those  of  the 
arms  and  face,  may  be  affected  by  the  choreic  movements.  The  eyelids 
twitch  irregularly,  the  ocular  muscles  proper  undergo  similar  involuntary 
contractions,  and  those  inserted  into  the  angles  of  the  mouth  twitch  in 
an  irregular  manner,  imparting  to  the  face  a  peculiar  expression,  some- 
times bordering  on  the  ludicrous,  sometimes  of  a  stern  character.  At 
times  the  mouth  is  thrown  widely  open  and  the  tongue  is  rapidly  pro- 
truded, to  be  as  quickly  withdrawn.  The  muscles  of  the  neck,  especially 
the  sterno-cleido-mastoids,  are  also  involved,  causing  the  head  to  bend 
rapidly  upon  the  chest,  to  be  thrown  backward,  or  to  be  tossed  from  side 
to  side.  In  rare  instances,  the  affection  is  confined  to  the  muscles  of  the 
neck,  and  the  head  is  continually  engaged  in  a  series  of  nodding  move- 
ments, constituting  the  so-called  chorea  nutans  of  Marshall  Hall.  It  is 
doubtful,  however,  whether  this  is  a  form  of  true  chorea.  The  muscles 
of  respiration  and  phonation  are  not  exempt  from  the  convulsive  phe- 
1 


2  FUNCTIONAL    NERVOUS    DISEASES. 

iiomena.  If  the  chest  is  bared,  it  will  be  found  that  inspiration  is 
frequently  interrupted,  before  the  act  is  complete,  by  a  sudden  expira- 
tory movement.  The  speech  of  the  patient  is  often  interrupted,  owing' 
to  the  irregularity  in  the  respiratory  rhythm.  This  disturbance  is  some- 
times so  marked  that  the  patients  must  take  a  deep  inspiration  between 
the  utterance  of  individual  words,  and  become  greatly  fatigued  after 
speaking  a  few  sentences.  According  to  Ziemssen,'  an  affection  of  the 
laryngeal  muscles  usually  accompanies  severe  cases  of  chorea.  By  means 
of  the  laryngoscope,  Ziemssen  was  able  to  detect  the  irregular  contractions 
of  the  different  muscles  which  are  engaged  in  varying  the  tension  of  the 
vocal  cords.  In  some  cases,  this  is  shown  by  the  loxo  pitch  and  monotony 
of  the  voice;  as  improvement  progresses,  these  phenomena  gradually  dis- 
appear. In  many  instances  the  hands  are  chiefly  affected.  Even  when 
the  child  is  perfectly  quiescent  and  without  any  voluntary  effort  on  his 
part,  the  hands  will  suddenly  become  forcibly  flexed  or  extended,  the  fin- 
gers Avill  be  separated  from  one  another,  and  the  hand  will  be  drawn 
away  from  the  body,  or  vice  versa.  If  the  patient  attempts  to  drink 
a  glass  of  water,  he  experiences  great  difficulty  in  grasping  the  glass, 
and  is  unable  to  carry  it  directly  to  his  mouth.  A  considerable  portion 
of  its  contents  is  spilled  in  the  endeavor  to  drink,  and  the  patient  may 
strike  the  vessel  against  his  cheek  or  nose.  The  legs  are  also  usually 
affected,  though  not,  as  a  rule,  to  such  an  extreme  degree  as  the  hands. 
In  walking,  the  knees  frequently  bend  under,  the  patient  trips  and  stum- 
bles on  account  of  the  ill-timed  contractions  of  the  extensors  or  flexors  of 
the  foot,  and  the  legs  often  become  entangled  in  one  another;  sometimes, 
however,  a  shuffling  gait  is  the  only  evidence  of  the  affection  of  the  legs. 
In  severe  forms  of  the  disease,  the  patient  is  in  a  truly  deplorable  condi^ 
tion.  The  movements  of  the  hands  may  be  so  intense  that  he  is  unable 
to  feed  himself,  and  when  the  muscles  of  mastication  and  deglutition  are 
implicated  to  an  extreme  degree,  the  sufferer  must  be  fed  through  the 
stomach-tube  or  by  means  of  nutritive  enemata.  Sometimes  the  patient 
is  unable  to  maintain  his  seat,  but  is  continually  jumping  up  and  down 
or  falling  from  his  chair.  Even  in  cases  of  moderate  severity',  locomotion 
is  often  rendered  difficult,  if  not  impossible,  by  the  irregular  contractions 
occurring  in  the  legs.  As  a  rule,  the  movements  cease  almost  entirely 
during  sleep  (although  rest  is  often  disturbed  by  frequent  fits  and  starts); 
but,  in  cases  of  extreme  severity,  sleep  is  rendered  impossible  by  tiie  vio- 
lence of  the  movements,  and  the  latter  continue  even  when  the  patient 
does  finally  fall  into  a  light  slumber.  Ulcerations  of  the  prominent  por- 
tions of  the  body,  from  the  continued  friction  against  surrounding  objects, 
supervene  in  these  cases,  and  inanition  and  exhaustion  rapidly  develop 
from  the  lack  of  nutrition  consequent  on  the  inability  to  eat,  from  the 
continuous  violence  of  the  choreiform  movements,  and  from  the  loss  of 
sleep. 

In  light  cases,  the  choreic  contractions  usually  occur  when  the  patient 
endeavors  to  perform  a  voluntary  act,  and  the  bizarre  movements  are 
then  due  to  associated  contractions  of  antagonistic  rpuscles.  In  the 
more  severe  forms,  the  movements  develop  irrespective  of  any  voluntary 
effort  on  the  part  of  the  patient,  and,  as  we  have  previously  mentioned, 
may  even  continue  uninterruptedly  during  sleep.  But  these  statements 
will  not  hold  good  in  all  cases  and  under  all  circumstances.     Gowers  ' 

'  Handb.  d.  spec.  Path.  u.  Therap.     Bd.  XII.  p.  415. 
«  Brit.  Med.  Journ.,  Mar.  30,  187«. 


CHOREA.  3 

found,  that,  in  chorea,  inco-ordination  of  voluntary  movement  bears  no 
relation  to  the  spontaneous  movements,  but  varies  independently  of  the 
latter.  Thus,  a  patient  in  whom  the  spontaneous  movements  were  very 
marked,  could  perform  voluntary  actions  with  great  ease  and  steadiness, 
while,  on  the  other  hand,  in  a  patient  with  scarcely  noticeable  spontane- 
ous movements,  the  inco-ordination  became  extreme  when  he  tried  to  exe- 
cute a  voluntary  effort.  The  independent  variation  in  these  two  elements 
in  chorea  suggests  that  they  may  depend  on  an  affection  of  distinct  and 
separate  regions  of  the  nerve-centres. 

This  state  of  affairs  appears,  however,  to  be  decidedly  exceptional. 
The  majority  of  authors  do  not  appear  to  have  had  a  similar  experience, 
and  I  do  not  recollect  a  single  case  in  which  the  statements  of  Gowers 
will  hold  good,  although  I  have  carefully  examined  in  this  particular  all 
the  patients  wlio  have  come  under  my  observation  since  reading  Gowers's 
article. 

The  movements  are  not  always  bilateral,  but  may  only  involve  one 
half  of  the  body,  and  tlien  constitute  a  variety  of  the  affection  usually 
known  as  hemichorea.  The  disease  not  infrequently  begins  as  a  hemi- 
chorea,  but  spreads  to  the  other  side  of  the  body  as  the  affection  pro- 
gresses. The  following  statistics  vrill  serve  to  show  the  relative  frequency 
of  tills  variety  of  the  disease: 

No.  of  cases.     Hemichorea. 

S6e 154  97 

Pye-Smith 150  33 

Russell 97  29    - 

Author 82  16 

Among  Pye-Smith's  33  cases  of  hemichorea,  15  affected  the  right  and 
18  the  left  side  of  the  body.  Althaus  reported  22  cases  of  hemichorea, 
of  which  16  involved  the  left  and  6  the  right  side  of  the  body;  Ogle,  24 
right,  20  left  hemichorea;  Russell,  18  right,  11  left.  These  facts  possess 
considerable  importance  and  we  shall  refer  to  them  hereafter  in  discussing 
the  pathology  of  this  affection.  In  rare  instances,  the  choreiform  move- 
ments are  even  more  limited  in  their  distribution  and  may  be  confined  to 
the  face  or  arm.  Jn  one  case  of  vertebral  caries  in  the  lower  lumbar  re- 
gion, which  Avas  under  my  observation,  the  patient,  a  boy  a;t.  16  years, 
began  to  suffer  from  well  developed  choreic  movements  of  the  left  forearm 
and  hand,  and  the  left  side  of  the  face,  these  phenomena  suddenly  mak- 
ing their  appearance  upon  the  day  after  he  had  seen  a  severe  case  of 
general  chorea  in  a  young  friend. 

It  is  a  curious  and  interesting  fact  that  the  patients  do  not  complain 
much  of  fatigue,  even  although  the  movements  are  quite  violent  and  con- 
tinuous. As  a  rule,  also,  there  is  little  or  no  loss  of  power  in  the  affected 
limbs,  though  in  some  cases  considerable  paresis  may  develop,  especially 
in  hemichorea.  The  intensity  of  the  paresis  does  not  appear  to  present 
any  definite  relation  to  the  severity  of  the  choreiform  movements.  A 
better  idea  of  the  loss  of  power  can  be  obtained  by  allowing  the  patient 
to  squeeze  the  hand  of  the  observer  than  by  using  the  dynamometer, 
since  the  manipulation  of  the  latter  requires  more  delicate  muscular  co- 
ordination than  the  former  procedure,  and  is  therefore  more  interfered 
with  by  the  choreic  movements.  In  rare  instances  the  muscles  become 
completely  paralyzed.  I  shall  report  in  full  the  following  case  of  general 
paralysis  due  to  chorea,  as  it  is  very  interesting  from  several  points  of 
view. 


4  FUNCTIONAL    NEEVOUS    DISEASES. 

Case  I. — The  patient,  Peter  K.,  ret.  of  years,  first  came  under  my  ob- 
servation at  the  clinic  for  Nervous  Diseases  in  the  Bellevue  Out-door  De- 
partment, on  April  ;22, 1878.  The  family  histor}-  is  unimportant;  neither  of 
the  parents  or  other  members  of  the  family  have  ever  suffered  from  rheuma- 
tism. The  patient  was  always  in  excellent  health  until  seven  weeks  pre- 
viously, when  he  suddenly  developed  considerable  fever,  followed  in  three 
days  b}^  swelling  of  the  knees  and  ankles,  the  joints  also  becoming  ex- 
ceedingly painful  to  the  touch.  This  condition  lasted  three  weeks,  and 
was  diagnosed  as  acute  articular  rheumatism  by  the  physician  in  attend- 
ance. Very  shortly  after  the  termination  of  the  rheumatic  attack  (about 
April  1st),  and  while  the  patient  was  apparently  doing  very  well,  he 
began  to  suffer  from  irregular  choreiform  twitchings  in  the  limbs,  which 
did  not,  however,  attain  any  considerable  severity.  A  few  days  after  this 
symptom  appeared,  the  child  awoke  one  morning  in  a  condition  of  great 
muscular  weakness,  and  was  unable  to  articulate,  although  speech  had 
hitherto  been  perfect.  The  paresis  gradually  grew  worse  until  a  week 
ago  (April  15th),  since  which  time  it  has  remained  in  statu  quo.  The 
twitchings  of  the  muscles  continued  up  to  the  present,  but  were  not  very 
marked. 

Present  condition  (April  22,  1878). — The  patient  is  a  large  child,  ap- 
parently well  nourished.  He  has  left  convergent  strabismus,  which  came 
on  after  a  slight  attack  of  diarrhoea,  that  occurred  last  July,  and  has  per- 
sisted ever  since.  Physical  exam.ination:  lungs  normal;  the  apex-beat  of 
the  heart  is  felt  at  the  nipple;  a  loud,  blowing  systolic  murmur  is  present, 
which  is  heard  most  distinctly  at  the  apex  and  is  also  conveyed  into  the 
left  axillary  space,  but  could  not  be  traced  into  the  scapular  region;  the 
second  cardiac  sound  is  heard  sharply  and  distinctlj',  and  is  not  accom- 
panied by  any  adventitious  sounds. 

The  patient  is  unable  to  swallow  solid  food,  and  this  condition  has 
lasted  since  the  beginning  of  the  paralysis.  There  is  considerable  weak- 
ness of  the  upper  limbs;  the  grasp  is  feeble,  and  the  patient  is  unable  to 
raise  his  hands  above  the  shoulders.  The  lower  limbs  are  even  weaker 
than  the  upper.  There  is  almost  complete  paralysis  of  the  anterior  mus- 
cles of  the  legs,  the  feet  hanging  in  the  position  of  talipes  equinus,  and 
the  toes  are  only  movable  to  a  very  slight  extent.  The  patient  is  barely 
able  to  flex  the  thighs  on  the  abdomen.  When  placed  in  a  sitting  posture 
the  child  immediately  topples  over  to  one  or  the  other  side,  apparently 
from  paralysis  of  the  dorsal  muscles.  The  muscles  throughout  the  entire 
body  feel  soft  and  flabby.  It  is  impossible  to  get  accurate  data  with 
regard  to  sensation,  on  account  of  the  age  of  the  patient;  reflex  action 
and  the  electro-muscular  reactions  are  normal  throughout  the  body. 
The  patient  is  unable  to  speak,  except  to  say  "yes  "  and  "  no,"  the  for- 
mer word  being  uttered  in  a  very  indistinct  manner.  Sleep  is  very  much 
disturbed.  The  natural  folds  of  the  face  are  almost  completely  effaced  and 
the  facial  muscles  appear  to  be  paretic,  if  not  entirely  payalyzed;  the  fea- 
tures present  a  dull  mask-like  appearance.  The  patient  is,  however,  able 
to  close  the  eyes  in  a  normal  manner.  There  is  very  little  power  of  mo- 
tion in  the  tongue,  the  organ  being  protruded  very  slowly  and  tremu- 
lously, and  only  to  a  slight  extent.  The  choreiform  movements  are  scarcely 
noticeable,  come  on  only  at  long  intervals,  and  are  ^'ery  moderate  in  in- 
tensity. I  ordered  milk  diet,  ol.  morrhuas,  and  a  mixture  composed  of 
tinct.  ferri  chlorid.  3  ij.,  potass,  chlorat.  3  j-,  and  syr.  simp,  f  iv.,  one  tea- 
spoonful  being  given  three  times  a  day.  The  child  began  to  mend  very 
rapidly,  and  on  May  22d  the  following  notes  were  taken:  the  patient  is 


CHOEEA.  O 

able  to  walk  almost  as  well  as  ever,  and  the  power  in  the  upper  extremi- 
ties is  apparently  entirely  restored;  slig-ht  choreiform  movements  still 
continue  from  time  to  time.  Speech  is  almost  perfect.  The  mother  states 
that  during  the  last  two  weeks  the  child  has  been  almost  demented,  and 
has  not  appeared  to  comprehend  the  simplest  ideas.  At  times  he  has 
apparently  had  hallucinations  of  sight.  On  one  occasion,  while  playing 
with  some  toys  on  a  sofa,  he  began  to  talk  with  imaginary  playmates, 
saving  "that  he  was  better  than  they."  At  other  times,  he  is  said  to 
have  had  hallucinations  of  various  kinds.  To-day,  however,  the  patient 
appears  quite  bright  and  intelligent. 

June  5th. — The  patient  was  again  brought  to  me  and  was  entirely 
well  in  every  particular,  except  that  the  heart-murmur  was  still  distinctly 
audible,  though  not  so  loud  as  formerly. 

This  case  is  unlike  those  in  which  the  muscles  become  paretic  during 
the  course  of  very  intense  choreic  movements;  in  fact,  the  latter  were  so 
slight  at  times  that  prolonged  observation  was  necessary  in  order  to 
detect  them. 

Cliiford  Albutt '  also  published  the  notes  of  an  attack  of  acute  chorea 
followed  by  a  state  of  general  paralysis. 

C.  Handheld  Jones '  narrates  the  case  of  a  girl  suffering  from  chorea, 
attended  with  extreme  paresis  of  the  limbs  and  trunk,  and  also  of  the 
tongue  and  pharynx;  no  rheumatism  or  heart-murmur  discoverable.  The 
patient  recovered  completely.  The  cases  in  which  an  attack  of  chorea 
precedes  hemiplegia  (pr^ehemiplegic  chorea),  and  those  in  which  it  follows 
the  latter  (post-hemiplegic  chorea),  together  with  the  allied  affection  known 
as  athetosis,  will  be  discussed  in  a  subsequent  section  of  this  article. 
Trousseau,  in  his  "  Lectures  on  Clinical  Medicine,"  mentions  the  case  of  a 
girl  set.  18  5'ears,  who,  after  an  attack  of  right  hemiplegia,  manifested 
symptoms  of  hemichorea  upon  the  paralyzed  side.  Trousseau  regarded 
this  case  as  one  of  ordinary  chorea,  but  there  is  very  little  doubt  that  it 
belongs  to  the  category  of  post-hemiplegic  chorea,  which  is  of  an  entirely 
different  nature,  and  the  patholoo-ical  sio-nificance  of  which  was  unknown 
at  the  period  during  which  this  observation  was  made. 

Very  few  investigations  have  been  made  with  regard  to  the  electrical 
reactions  of  the  nerves  and  muscles  in  chorea.  Rosenthal '  resorted  to 
electrical  exploration  in  three  cases  of  hemichorea  observed  soon  after  the 
onset  of  the  disease  (for  obvious  reasons  it  is  useless  to  make  examina- 
tions of  this  nature  in  cases  in  which  the  choreic  movements  occur  upon 
both  sides  of  the  body).  He  found  a  marked  increase  of  electro-muscular 
contractility  in  the  affected  muscles.  Rosenthal  observed  very  marked 
excitability  to  the  galvanic  current,  which  was  manifested  by  contractions 
upon  closure  at  the  negative  pole,  by  galvano-tonic  contractions  with 
weak  currents,  and  by  contractions  upon  opening  at  the  cathode.  In- 
creased irritability  of  the  sensory  nerves  was  also  manifested.  Gowers  * 
states  that  a  few  weeks  after  the  onset  of  the  affection  there  is  observed 
in  most,  though  not  in  all  cases,  a  distinct  increase  in  the  irritability  of 
the  nerves  and  muscles  of  the  affected  side,  both  to  the  faradic  and  the 
galvanic  currents.     The  difference  varied  from  1 — 2  centimetres  of  the 

'  Medical  Times  and  Gazette  for  1878. 

'  Practitioner,  vol.  xxi. ,  1878. 

2  A  Clinical  Treatise  on  Diseases  of  the  Nervous  System,  1878. 

4  Brit.  Med.  Journ.,  March  80,  1878. 


6  FUNCTIONAL    NERVOUS    DISEASES. 

secondary  coil  of  Stoehrer's  larger  induction  apparatus,  and  from  2 — 5 
cells  of  Stoehrer's  or  Leclanche's  galvanic  battery.  The  increased  irrita- 
bility diminished  with  the  subsidence  of  the  chorea. 

Mv  experience  disproves  the  applicability  of  these  statements  to  all 
cases  of  chorea.  In  one  case  of  hemichorea  the  faradic  excitability  of  the 
muscles  of  the  affected  side  was  notably  increased,  but  the  reactions  of 
the  muscles  and  nerves  to  the  galvanic  current  were  equal  on  the  two 
sides.  In  six  other  cases  of  hemichorea,  which  I  examined  with  refer- 
ence to  these  points,  the  electrical  reactions  were  similar  on  both  sides  of 
the  bodv.  In  only  three  of  these  patients,  however,  was  I  able  to  make 
the  examination  during  the  first  period  of  the  disease;  in  the  others  the 
chorea  had  lasted  upward  of  a  month. 

Not  infrequently  heart-murmurs  are  heard,  which — in  the  absence  of 
previous  rheumatism  or  other  causes  of  valvular  lesions,  of  hypertrophy 
or  dilatation  of  the  heart,  and  of  other  symptoms  indicative  of  organic 
disease  of  this  organ — should  be  regarded  as  merely  dynamic  in  charac- 
ter. Some  authorities  consider  such  murmurs  as  purely  ansemic,  while 
others  suppose  that  they  are  due  to  irregular  choreiform  contractions  of 
the  papillary  muscles  of  the  heart,  which  thus  prevent  the  proper  closure 
of  the  leaflets  of  the  various  valves  at  certain  intervals.  But  this  view 
is  strongly  contradicted  by  the  fact  that  it  is  very  doubtful  whether 
choreic  movements  occur  in  the  heart.  As  we  shall  see  later,  some 
authorities  think  that  these  choreiform  movements  of  the  papillary  mus- 
cles are  capable  of  giving  rise  to  endocarditis,  and  explain  in  this  manner 
the  frequent  occurrence  of  vegetations  upon  the  mitral  valves  in  fatal 
cases  of  chorea.  At  times,  indeed,  I  have  observed  irregularity  of 
the  heart's  action  in  patients  suffering  from  chorea,  but  this  has  only 
been  noticed  in  very  anaemic  patients,  and  therefore  due  to  the  condition 
of  the  blood,  or  it  has  occurred  during  violent  choreiform  movements  of 
the  respiratory  muscles.  In  the  latter  cases  it  appears  to  me  to  be  due 
to  the  irregular  character  of  the  respirations,  the  rhythm  of  which,  as 
physiologists  have  taught  ^s,  exerts  considerable  influence  upon  the 
action  of  the  heart. 

The  existence  of  chorea  of  the  bladder  is  also  a  disputed  point.  The 
majority  of  neurologists  deny  that  the  involuntary  muscular  fibres  are 
ever  the  seat  of  choreiform  contractions.  Van  Buren  and  Keyes  '  men- 
tion three  cases  of  chorea  of  the  bladder  which  came  under  their  notice, 
only  one  of  which,  however,  is  entirely  conclusive,  and  which  we  copy  in 
full 

Case  II. — "Aged  eight,  is  a  fat,  healthy,  lymphatic  boy;  one  of  a 
large  family  of  children,  of  whom  nearly  ever}'  male  has  distinct  chorea, 
either  generalized  or  affecting  special  muscles.  Some  of  the  older  chil- 
dren have  outgrown  the  tendency.  The  patient  is  troubled  occasionally 
with  slight  general  choreic  twitchings,  w^hen  from  any  cause  his  appetite 
is  low,  or  his  general  health  poor.  Under  such  circumstances  he  has  fre- 
quent paroxysms  of  intermitting,  uncontrollable  contraction  of  the  blad- 
der, forcing  him  to  frequent  micturition  and  attempts  at  emptying  the 
bladder  every  few  moments.  Sometimes  the  call  comes  so  suddenly  that 
he  wets  his  clothing,  and  he  also  is  unfortunate  at  night.  When  the  boy 
is  enjoying  good  general  health,  neither  his  general  chorea  nor  his  fre- 

*  Genito-iirinary  Diseases  with  Syphilis,  1874,  p.  231. 


CHOREA.  7 

quent  calls  to  urinate  disturb  him.     lie  improves  under  arsenic,  quinine, 
or  any  general  tonic  or  country  air." 

I  have  also  observed  a  case  of  chorea  in  which  the  patient,  although 
previously  able  to  retain  his  urine,  was  frequently  seized  with  inconti- 
nence which  came  on  suddenly,  and  which  I  could  only  explain  on  the 
hypothesis  that  the  symptom  was  due  to  sudden,  choreiform  contractions 
of  the  detrusor  urinjB.  After  the  chorea  subsided,  the  patient  was  again 
able  to  retain  his  urine  as  usual. 

As  a  general  rule,  both  pupils  are  considerably  dilated  in  this  disease, 
and  do  not  respond  readily  to  light.  I  have  not  observed  any  noteworthy 
difference  in  their  condition  in  hemichorea.  The  appearance  of  the  pupils 
is  not,  however,  characteristic  of  this  affection,  and  is  frequently  ob- 
served in  children  whose  health  is  below  par.  Rosenthal  reports  one  case 
in  which,  at  the  height  of  the  paroxysm,  he  observed  very  marked  dilata- 
tion of  both  pupils,  which  was  not  modified  by  exposure  to  a  bright  light 
or  by  introducing  a  small  electrode  between  the  sclerotic  and  conjunctiva. 
The  pupillary  dilatation  disappeared  spontaneously  at  the  termination  of 
the  disease. 

Dr.  H.  R.  Swanzy  '  reports  a  case  in  which  an  ophthalmoscopic  ex- 
amination in  a  choreic  girl  (whose  choreiform  movements  developed  simul- 
taneously with  blindness  of  the  left  eye)  showed  the  appearances  indicative 
of  embolism  of  the  central  artery  of  the  retina.  After  the  lapse  of  five 
weeks,  the  retinal  circulation  was  restored,  and  the  chorea  likewise  ceased 
about  the  same  time.  Three  months  later,  this  patient  was  suddenly 
seized  with  complete  paralysis  of  the  seventh  nerve  on  the  right  side.  Five 
days  afterward,  violent  and  persistent  vomiting  occurred,  which  continued 
all  night  and  the  following  morning,  and  appeared  to  be  of  a  cerebral 
character.  The  sense  of  taste  on  the  right  half  of  the  tongue  was  some- 
what  impaired.  Three  months  after  the  beginning  of  the  paralysis  the 
child  was  growing  stronger  and  the  paralysis  had  improved  considerably. 
Dr.  Swanzy  regarded  the  paralytic  affection  as  indicative  of  an  organic 
cerebral  lesion.  It  is  unfortunate  that  no  note  was  made  of  the  electrical 
reactions  of  the  affected  nerve  and  muscles;  but  from  the  fact  that  the 
paralysis  was  said  to  be  complete,  and  that  the  sense  of  taste  was  im- 
paired, we  should  regard  the  former  as  more  probably  peripheral  in  its 
origin. 

Some  authors  state  that  sensory  disturbances  are  quite  common  in 
chorea,  while  others  barely  mention  their  occurrence.  The  French  writers 
especially  maintain  that  hemianfesthesia  is  a  frequent  concomitant  of 
hemichorea,  and  that  in  some  cases  the  special  senses  are  affected.  Although 
my  attention  has  been  directed  to  this  point  for  several  years,  I  have  not 
been  able  to  verify  the  observation.  It  is  more  than  probable  that  many 
of  the  cases  of  chorea  in  which  hemian:esthesia  has  been  a  prominent 
symptom,  have  been  really  examples  of  post-hemiplegic  chorea,  and  there- 
fore belong  to  another  category.  At  other  times,  general  hyperffis- 
thesia  of  the  surface  has  been  noticed,  or  vague,  wandering  pains  in 
the  muscles  and  joints.  Especial  importance  has  been  attached  to  ten- 
derness upon  pressure  over  the  spinal  column,  particularly  in  the  cer- 
vical and  upper  dorsal  regions.  Stiebel,  Rosenbach,  and  Seifert  have  laid 
great  stress   upon  the  value  of  this  symptom  from  a  pathological  and 

'  Ophthalm.  Hosp.  Rep.,  Sept.,  1875, 


8  FUNCTIOTTAL    NEEVOUS    DISEASES. 

therapeutic  standpoint.  Rosenbach  showed  (and  I  have  verified  his  state- 
ment on  several  occasions)  that  the  passage  of  a  constant  galvanic  current 
through  the  spinal  column  will  reveal  the  presence  of  tender  points,  at 
times  when  they  are  not  appreciable  upon  pressure  with  the  finger.  But 
these  tender  points  are  not,  by  any  means,  invariably  present  in  chorea, 
and  some  writers  have  been  unable  to  detect  them.  If  we  bear  in  mind 
the  great  frequency  of  this  symptom  in  hysteria,  spinal  irritation  and 
general  nervous  prostration,  we  will  not  be  tempted  to  lay  much  weight 
upon  its  appearance  in  chorea.  I  know,  from  personal  observations, 
that  physicians  will  sometimes  regard  this  symptom  as  present  when 
more  careful  examination  shows  that  the  position  of  the  tenderness  varies 
from  time  to  time  during  the  course  of  a  single  examinatioUj  is  absent 
when  attention  is  diverted,  etc. 

Mental  disturbances  are  rarely  absent  in  chorea.  As  we  have  men- 
tioned in  the  beginning  of  this  article,  the  children  usually  become  peevish, 
irritable,  and  obstinate,  at  the  onset  of  the  affection.  We  desire  to  call  at- 
tention emphatically  to  these  symptoms,  since  they  are  almost  invariably 
present,  whether  the  disease  be  mild  or  severe,  and  because,  in  our  judg- 
ment, they  furnish  important  indications  of  the  position  of  the  lesion  in 
the  affection  under  consideration.  But  in  rarer  instances,  true  insanity 
develops  during  the  course  of  chorea.  Arndt,'  who  called  attention  to 
the  close  relationship  which  exists  between  the  two  diseases,  states  that 
many  cases  of  insanity  merely  represent  the  transmission  of  the  chorea 
from  the  motor  to  the  intellectual  centres  of  the  brain.  Insanity  de- 
velops more  frequently  during  chorea  than  is  usually  supposed.  Krafft- 
Ebing  ^  divides  this  form  into  three  classes,  viz.,  mania,  melancholia, 
and  a  variety  characterized  by  delusions  of  demonomaniac  persecution. 
He  regards  them  as  "inanition-psychoses,"  caused  by  exhaustion  induced 
by  the  violent  character  of  the  muscular  movements,  and  by  the  dimin- 
ished sleep.  It  is  more  than  doubtful,  however,  whether  these  views  will 
hold  good  with  regard  to  all  cases  of  this  character,  and  one  of  my  cases,  at 
least,  can  not  be  included  in  this  category.  The  insanity  commonly  oc- 
curs at  the  height  of  the  choreic  affection  and  the  mental  manifestations 
present  a  disjointed  character,  furnishing  an  analogue,  as  Arndt  pointed 
out,  to  the  phenomena  observed  in  the  muscles.  Chorea  sometimes  simu- 
lates insanity  although  the  mental  powers  are  intact.  Thus,  the  patients 
may  appear  to  be  incoherent  in  their  speech,  owing  to  the  fact  that  articu- 
lation is  interrupted  by  choreic  movements  of  the  muscles  of  phonation, 
giving  rise  to  the  involuntary  utterance  of  words  or  disjointed  sentences, 
foreign  to  the  matter  under  discussion.  This  apparent  incoherence  of 
ideas,  together  with  the  destructive  tendencies  manifested  by  the  patient 
on  account  of  his  lack  of  control  over  the  muscles,  has  led  physicians,  in 
several  instances,  to  make  a  diagnosis  of  insanity  although  the  intellec- 
tual manifestations  were  entirely  normal.  A.n  English  alienist,  whose 
name  escapes  me,  has  reported  two  cases  of  this  nature  which  had  been 
committed  to  an  insane  asylum.  The  ordinary  course  of  choreic  mania  is 
exemplified  by  the  history  of  the  following  patient  under  my  charge. 

Case  HI. — Fanny  M.,  jet.  17^  years;  family  history  is  entirely  negative 
as   regards    any  neuropathic  tendencies.     The   patient    always    enjoyed 

'Arch.  f.  Psych.     Bd.  I. 

2  Handb.  f.  Psychiatrie.     Bd.  I.,  1879. 


CHOREA.  y 

g-ood  health  until  the  beginning  of  the  present  ailment.  Last  August 
(1878).  the  patient  caught  cold  while  menstruating,  causing  a  sudden  arrest 
of  the  menstrual  discharge.  A  week  later,  she  began  to  have  choreiform 
twitchings  upon  the  right  side  of  the  body,  and  these  soon  increased  in 
severity.  After  the  lapse  of  a  month,  the  left  side  also  became  involved, 
but  the  movements  have  never  been  so  violent  as  upon  the  right  side  of 
the  body.  Toward  the  end  of  September,  the  patient  had  a  bad  attack 
of  "  nightmare,"  and  during  the  next  five  or  six  weeks,  gave  marked  indi- 
cations of  insanity.  For  some  time  she  refused  to  eat,  stating  that  her 
food  was  poisoned,  and  that  she  was  being  persecuted  by  strangers.  She 
evinced  hostile  feelings  toward  her  family,  especially  toward  the  mother, 
whom  she  called  vile  names,  etc.  At  times  she  was  unable  to  recognize 
her  relatives  and  acquaintances,  and  thought  that  her  female  relations 
were  men  dressed  in  women's  clothes.  The  patient  was  also  vicious  and 
violent,  destroying  her  clothes  and  articles  of  furniture.  During  this  time 
the  choreic  movements  became  extremely  severe  and  continued  even  dur- 
ing sleep,  so  that  the  patient's  limbs  had  to  be  tied  down  in  bed.  The 
muscular  twitchings  then  rapidly  improved  and  the  symptoms  of  insanity 
disappeared  at  the  same  time.  Tlie  chorea  did  not,  however,  stop  en- 
tirely and  was  present  to  a  moderate  degree  when  the  patient  first  came 
under  my  observation.  I  then  prescribed  Fowler's  solution,  beginning 
with  five-drop  doses  three  times  daily,  and  increasing  rapidly  until  twelve- 
drop  doses  were  taken.  Within  a  week  after  beginning  this  plan  of  treat- 
ment, the  menses,  which  had  been  suppressed  since  last  August,  returned, 
and  within  a  month  the  choreiform  movements  were  no  longer  noticeable. 
June  19,  1879,  the  patient  returned,  stating  that  the  choreiform  move- 
ments were  returning  on  the  right  side  of  the  body.  She  was  again  put 
on  the  use  of  Fowler's  solution,  gtt.  viij.  t.  i.  d.,  and  rapidly  improved. 
Apart  from  a  certain  amount  of  fretfulness  and  slight  loss  of  memory, 
there  were  no  mental  disturbances  during  this  attack;  the  muscular 
twitchings  were  also  of  a  comparatively  mild  character. 

In  this  case  the  mental  aberration  was  most  marked  during  the  height 
of  the  affection,  when  the  choreic  movements  were  so  violent  that  they 
did  not  even  cease  during-  sleep,  and  necessitated  the  application  of  stout 
bandages  to  the  patient's  trunk  and  limbs  in  order  to  prevent  her  doing 
injury  to  herself.  As  in  the  case  just  reported,  the  prognosis  of  this  form 
of  choreal  mania  is  good.  In  the  majority  of  instances  the  mental  dis- 
turbances disappear  as  soon  as  the  other  symptoms  have  subsided,  or 
within  a  couple  of  months  afterward.  Cases  of  maniacal  chorea  furnish, 
however,  a  large  contingent  of  the  mortality  in  this  disease,  not  so  much 
on  account  of  the  complication  with  insanity,  but  beoause  the  choreic 
movements  are  so  severe  that  they  interfere  with  sleep  and  nutrition.  In 
other  individuals,  also,  the  manifestations  of  insanity  persist,  despite  the 
disappearance  of  the  choreiform  movements  and  a  return  of  the  patient, 
in  other  respects,  to  a  state  of  health.  The  following  observation  fur- 
nishes a  good  example  of  this  nature: 

Case  IV. — Wm.  K.,  set.  8  years;  patient's  great-gran  daunt  was  in- 
sane; grandfather  died  of  apoplexy;  a  granduncle  was  an  inebriate;  a 
brother  suffers  from  epilepsy;  the  mother  is  nervous  and  hysterical,  but 
states  that  this  condition  has  only  developed  in  late  years  from  worry  and 
distress  connected  with  the  health  of  her  children ;  no  member  of  the  family 
has  ever  suffered  from  rheumatism.  The  patient  had  measles  and  whooping- 


10  FUNCTIONAL    NERVOUS    DISEASES. 

cough  during  infancy;  when  three  weeks  old,  he  suffered  from  pneumonia 
and  had  a  number  of  convulsions  during  his  illness;  also  had  two  convul- 
sions at  the  beginning  of  the  attack  of  measles.  At  the  age  of  3  years 
and  5  years  he  had  acute  articular  rheumatism.  He  also  had  another  at- 
tack of  rheumatism  about  18  or  19  months  ago,  which  lasted  a  week. 
Two  years  ago  he  began  to  have  choreiform  twitchings,  which  grew 
worse  in  the  spring  and  almost  entirely  disappeared  after  the  lapse  of  a 
year.  But  even  at  the  present  time  considerable  muscular  twitching  be- 
comes apparent  if  the  patient  is  very  much  excited;  when  he  is  calm  the 
choreiform  movements  are  not  noticeable. 

Last  summer  (18T8)  the  patient  began  to  act  strangely.  ^Yhile  at 
school  he  became  extremely  insubordinate,  and  displayed  evidences  of 
very  bad  temper.  Upon  one  occasion  he  cut  a  playmate  with  a  knife 
on  account  of  a  trifling  dispute.  During  last  September  he  began  to  en- 
tertain the  delusion  that  objects  around  him  were  placed  crooked.  While 
sitting  at  table,  he  would  carefully  smooth  out  the  wrinkles  in  the  table- 
cloth, was  continually  moving  the  dishes  in  order  to  make  them  straight, 
and  stated  that  the  chairs  and  pictures  were  crooked.  Finally,  he  ate 
from  a  low  bench  placed  upon  his  knees,  "  on  account  of  his  inability  to  get 
the  table  straight."  About  the  same  time,  he  began  to  manifest  an  aver- 
sion to  his  mother,  to  whom  he  had  been  fondly  attached.  During  the 
summer  he  was  continually  finding  fault  with  his  clothes — at  one  time  the 
sleeves  were  too  short,  and  then  too  long.  Finally,  he  began  to  tear  off  his 
clothes  and  would  run  around  naked,  stating  that  the  garments  hurt  him. 
The  patient  also  had  delusions  of  sight  and  hearing.  Sleep  was  very  much 
disturbed  unless  hydrate  of  chloral  was  administered.  The  appetite  was 
very  capricious,  so  that  at  times  he  would  eat  gluttonously  and  then  again 
would  lose  all  desire  for  food.  The  patient  would  wake  up  very  tired  in  the 
morning;  he  has  never  had  any  epileptic  fits  during  the  day,  nor  have  any 
been  noticed  at  night  (slept  with  his  father  who  is  a  very  light  sleeper). 
He  has  gone  to  the  window  several  times  and  threatened  to  jump  out; 
also  threatened  to  commit  suicide  by  catting  himself  with  a  knife.  Has 
stated  that  he  would  rather  be  dead  than  alive,  and  remai-ked  to  his 
mother  "  that  she  would  also  prefer  death  if  she  felt  like  him,  though  he 
does  not  suffer  from  headache."  Upon,  being  questioned  he  is  either  un- 
willing or  unable  to  state  the  character  of  his  suffering.  His  insane  con- 
dition is  not  constant,  but  alternates  with  lucid  intervals  which  are  more 
frequent  and  longer  than  they  were  last  year. 

May  15,  1880. — The  patient  has  been  under  my  observation  since  the 
summer  of  1878,  and,  although  the  mental  symptoms  appeared  to  im- 
prove for  a  time,  they  have  presented  a  relapse  during  the  last  six  months, 
so  that  his  condition  is  almost  the  same  now  that  it  was  two  years  ago. 
The  chorea,  which  had  -entirely  disappeared,  has  begun  to  develop  again 
since  the  beginning  of  this  month. 

Chorea  is  also  associated  at  times  with  other  convulsive  affections,  es- 
pecially epilepsy.  More  frequently,  however,  we  find  that  epilepsy  devel- 
ops in  other  members  of  the  family.  In  rarer  instances,  a  child  who  was 
choreic  in  early  life,  becomes  epileptic  in  early  manhood  and  finally  pre- 
sents evidences  of  insanity.  Such  a  condition  is  almost  invariably  indica- 
tive of  a  severe  hereditary  neuropathic  tendency.  Among  the  cases  un- 
der my  observation,  only  four  were  complicated  with  epilepsy.  The 
chorea  may  follow  the  epileptoid  seizures,  or  may  precede  them  by  a  vari- 
able period.     Epileptiform  seizures  may  also  occur  during  the  progress 


CHOREA.  11 

oi  the  chorea,  as  occurred  in  one  of  my  patients,  who  presented  the  fol- 
lowing history: 

J     Case  V, — Ellen  D ,   jet.   17  years,   family  history  entirely  neq-a- 

tive  as  regards  any  hereditary  tendencies.  During  childhood  the  patient 
had  whooping-cough  and  measles,  and  passed  through  an  attack  of 
scarlatina  at  the  age  of  9.  The  menses  appeared  at  the  age  of  1.3  and 
have  been  regular  and  normal  up  to  the  present  time.  The  patient  has 
suffered  from  left  hemichorea  for  the  past  five  or  six  years;  the  dis- 
ease developed  gradually  and  without  any  known  cause.  Upon  repeated 
inquiry,  it  is  found  that  the  patient  has  masturbated  almost  daily  since 
she  was  four  years  of  age.  The  choreiform  movements  present  a  mode- 
rate intetisity  and  are  exclusively  confined  to  the  left  side  of  the  face  and 
body.  They  have  continued  uninterruptedly  since  the  beginning  of  the 
disease,  disappearing  during  sleep.  The  muscular  reactions  to  the  fara- 
dic  current  are  equal  on  both  sides  of  the  body.  The  measurements  of 
the  arms  are  alike  and  there  is  no  loss  of  power  upon  the  affected  side; 
sensation  is  also  normal.  About  four  years  ago,  the  patient  began  to 
have  "weak  spells"  {petlt-77ial),  during  which  she  became  dizzy,  weak, 
and  unconscious.  She  sometimes  wakes  up  in  the  morning  feeling  tired 
and  worn  out  (possibility  of  nocturnal  epilepsy).  She  has  on  an  average 
about  one  epileptic  attack  per  month,  but  its  development  does  not  ap- 
pear to  be  related  in  any  manner  to  the  period  of  menstruation.  During 
the  last  six  months  the  patient's  memory  has  become  somewhat  im- 
paired, and  during  the  past  two  months  she  has  become  quite  cross 
and  irritable.  At  times,  she  experiences  a  sharp  pain  in  the  pras- 
cordial  region,  and  is  forced  to  stand  still'  and  hold  her  breath  until  the 
pain  subsides.  These  attacks  are  not  accompanied  by  a  feeling  of  terror 
or  by  pain  or  numbness  in  the  left  arm.  Upon  physical  examination,  the 
apex  of  the  heart  is  found  a  little  to  the  left  of  the  nipple  and  a  slight 
thrill  is  felt.  The  valvular  sounds  are,  however,  perfectly  sharp  and 
distinct. 

In  this  case,  although  the  choreiform  movements  have  continued  for 
a  number  of  years  and  were  always  confined  to  one  side  of  the  body, 
the  absence  of  headache,  eye-trouble,  disorders  of  the  cerebral  nerves, 
and  of  paralysis  of  motion  or  sensation  in  the  limbs,  precludes  the 
idea  of  an  organic  lesion  as  the  cause  of  the  chorea  and  epilepsy.  It 
is  much  more  probable  that  both  affections  are  simply  functional,  and 
that  the  more  severe  neurosis  (epilepsy)  is  due,  in  the  absence  of  any 
hereditary  taint,  to  the  long  continuance  of  the  habit  of  masturbation, 
added  to  a  primary  (perhaps  congenital)  increased  irritability  of  the  nerve 
centres. 

It  is  probable,  also,  from  the  history  of  the  other  cases  of  this  nature 
■which  have  come  under  my  observation  that  they  were  due,  in  part  at 
least,  to  excessive  masturbation.  Three  cases  occurred  in  unmarried 
females,  and  one  in  a  young  widow,  all  of  whom  confessed  to  the  frequent 
performance  of  self-pollution.  As  we  shall  see  later  on,  however,  it  is 
not  an  easy  matter  to  determine  the  influence  of  the  secret  vice  in  the 
production  of  functional  nervous  diseases. 

The  chorea  of  pregnancy  (chorea  gravidarum)  demands  a  few  special 
remarks,  on  account  of  certain  peculiarities  connected  with  it.  Perhaps 
the  larger  proportion  of  cases  of  chorea  occurring  in  adult  life  belong  to 
this  category,  though  even  in  pregnant  women  the  disease  is  of  infrequent 


12  FU]SrCTTO]S"AL    NEEVOUS    DISEASES. 

occurrence,  Barnes/  who  made  a  very  careful  analysis  of  the  literature 
of  the  subject,  was  only  able  to  collect  56  cases.  Bodo  Wenzel"  collected 
the  histories  of  ten  additional  cases  which  had  been  reported  in  the  jour- 
nals from  1869—1874. 

I  have  had  no  personal  experience  with  regard  to  this  complication  of 
pregnancy,  and  shall,  therefore,  merely  give  an  abstract  of  the  conclusions 
arrived  at  by  Barnes  and  Bodo  Wenzel.  I  may  state  that,  with  the  ex- 
ception of  the  statistics  compiled  by  these  writers,  very  few  cases  have  been 
reported. 

The  majority  of  cases  occur  in  primiparae  between  the  ages  of  20 — 25 
years.  Among  57  cases,  22  occurred  in  the  first  three  months  of  preg- 
nancy, and  23  from  the  fourth  to  sixth  months.  In  very  rare  instances, 
the  chorea  makes  its  first  appearance  after  delivery  has  been  accomplished. 
In  14  cases  out  of  06,  the  patients  had  previously  suffered  from  one  or 
more  attacks  of  chorea.  The  chorea  of  pregnancy  is  especially  remarka- 
ble for  its  fatality.  Thus,  there  were  18  fatal  cases  among  the  66  col- 
lected by  Barnes  and  Wenzel,  or  more  than  27  per  cent.  In  the  fatal 
cases,  the  disease  usually  begins  suddenly  with  great  intensity  and  is 
often  accompanied  by  considerable  febrile  disturbance,  or  by  maniacal 
attacks.  Death  is  generally  due  to  exhaustion  produced  by  the  violence 
of  the  choreic  movements  and  the  loss  of  sleep  and  deprivation  of  nutri- 
tion attendant  upon  the  maniacal  excitement.  The  disease  appears  to 
have  little  or  no  effect  upon  the  termination  of  pregnancy.  As  a  rule, 
however,  the  choreiform  movements  rapidly  disappear  after  the  delivery 
of  the  child.  In  7  cases  the  onset  of  the  affection  was  attributed  to 
fright;  in  7  other  cases,  also,  the  disease  was  preceded  by  rheumatism 
and  endocarditis. 

The  occurrence  of  chorea  in  one  pregnancy  appears  to  predispose  to 
its  recurrence  in  succeeding  ones.  We  shall  refer  to  the  therapeutics  of 
this  variety  of  the  disease  under  the  general  head  of  treatment. 


POST-HEMIPLEGIC  ChOKEA. 

In  concluding  the  clinical  history  of  chorea  we  shall  give  a  short  de- 
scription of  the  allied  affections,  known  as  post-hemiplegic  and  pras-hemi- 
plegic  chorea,  and  athetosis.  Weir  Mitchell  ^  was  the  first  to  call  especial 
attention  to  the  form  which  he  aptly  termed  post-hemiplegic  chorea, 
though  Trousseau,*  in  his  article  on  chorea  stated  that  "  in  some  still 
rarer  instances  paralysis  (I  do  not  mean  a  mere  diminution  of  muscular 
strength,. but  true  paralysis),  precedes  the  manifestation  of  convulsive 
phenomena."  Although  some  advances  have  been  made  in  the  pathology 
of  post-hemiplegic  chorea,  very  little  has  been  added  to  our  knowledge 
of  the  clinical  history  of  the  affection  since  the  publication  of  Mitchell's 
article.  My  own  experience  has  been  entirely  confirmatory  of  the  views 
advanced  by  this  author. 

Clinical  history. — This  affection  is  a  hemichorea  occurring  at  a  longer 
or  shorter  interval,  after  the  development  of  a  cerebral  hemiplegia,  and 
always  occupying  the  same  side  as  the  motor  paralysis.     The  period  of 

'  Obstetrical  Transactions,  vol.  x.,  1869. 
«  Schmidt's  Jahrb.,  1874. 
'  Amer.  Journ.  Med.  Sciences,  1874. 
*  Lectures  on  Clinical  Medicine. 


CHOREA.  13 

its  development  varies  (usually  from  a  month  to  a  year  after  the  onset  of 
the  paralysis),  and  the  choreiform  movements  generally  make  their  appear- 
ance after  the  power  of  motion  in  the  limbs  has  been  considerably  re- 
stored. It  has  also  been  found  that  the  affection  is  almost  invariably  at- 
tended with  a  slight  amount  of  contracture  in  the  paralyzed  limbs.  The 
character  of  the  movements  does  not  differ  from  that  of  ordinary  chorea, 
except  that  they  are  more  apt  to  be  absent  while  the  patient  keeps  the 
limb  quiet,  and,  like  choreic  twitchings,  they  cease  during  sleep.  It  is  a 
carious  fact  that,  while  the  affection  is  comparatively  rare  after  the  hemi- 
plegia of  adults,  it  is  very  common  in  the  cerebral  hemiplegia  of  infancy 
and  cliildhood,  as  had  been  noticed  by  Weir  Mitchell.  I  may  remark 
here  as  an  interesting  circumstance,  that  cerebral  hemiplegia  of  infancy 
and  early  childhood,  when  not  followed  by  post-hemiplegic  chorea,  almost 
always  becomes  complicated  with  epilepsy  or  hystero-epileptiform  seizures. 
To  this  rule  I  liave  found  very  few  exceptions. 

In  the  large  majority  of  cases  post-hemiplegic  chorea  follows  cerebral 
hemorrhage,  although  it  may  also  occur  in  the  course  of  hemiplegia  due 
to  embolism,  thrombosis,  tumors,  cerebral  atrophy  of  childhood,  or  abscess 
of  the  brain. 

According  to  French  authors,  especially  Charcot'  and  Raymond,'  the 
motor  disturbances  of  post-hemiplegic  chorea  are  frequently  combined 
with  sensory  disorders.  Thus,  among  30  cases  of  this  affection  collected 
by  Raymond  (chiefly  from  the  wards  of  La  Salpotriere),  10  were  compli- 
cated with  hemianfesthesia.  The  anaesthesia  not  alone  affects  the  gene- 
ral sensibility,  but  may  also  involve  all  of  the  special  senses.  Among  my 
own  cases  I  have  been  unable  to  dffecover  any  disorders  of  sensation.  I 
should,  however,  state  that  I  have  chiefly  observed  this  affection  in  young 
children,  in  whom  it  is  very  difficult  to  obtain  any  accurate  data  with  re- 
gard to  sensation. 

Among  10  cases  analyzed  by  Gowers'  hemianfesthesia  was  only  ob- 
served four  times.  Hemiopia  was  present  in  two  of  these  cases,  but  in 
one  of  them  it  was  on  the  side  opposite  to  the  hemiplegia,  and  was  evi- 
dently due  to  a  distinct  lesion. 

Pre-hemiplegic  chorea  is  similar  in  its  clinical  characters  to  the  post- 
hemiplegic variety,  varying  only  with  regard  to  the  date  of  its  appear- 
ance. It  usually  occurs  from  a  few  hours  to  several  days  before  the  full 
development  of  paralysis,  ?md  subsides  as  soon  as  the  hemiplegia  becomes 
well  marked  or  complete. 

After  the  paralysis  has  improved,  the  choreiform  movements  may 
again  return  and  run  the  same  course  as  the  post-hemiplegic  variety. 
Pre-hemiplegic  chorea  is  much  more  infrequent  than  the  kindred  affec- 
tion. 

Charcot  and  his  followers  insist  very  strongly  that  the  motor  affection 
under  consideration  is  characteristic  of  a  lesion  situated  in  a  well-defined 
portion  of  the  brain,  viz.:  the  posterior  part  of  the  internal  capsule  and 
of  the  optic  thalamus  and  caudate  nucleus.  Although  Raymond  has  shown 
that  this  is  very  generally  the  case,  investigations  by  other  authors  have 
disproven  the  universal  application  of  this  statement. 

Thus,  Weir  Mitchell  found  a  lesion  of  the  corpus  striatum  in  two  cases 
of  post-hemiplegic  chorea,  and  Gowers  observed  a  cicatricial  induration 
At . 

'  Lemons  sur  les  maladies  du  sysleme  nerveux,  1877. 
*  Etude  anatomique  sur  I'hcmichoree,  etc.,  1876. 
*Med.-chir.  Trans.,  1876. 


14  FUNCTIONAL    NERVOUS    DISEASES. 

of  the  optic  thalamus,  extending'  across  its  centre  beneath  the  upper  sur- 
face and  approaching  at  its  outer  part,  but  not  involving,  the  ascending 
white  fibres  from  the  crus  cerebri.  In  a  case  reported  by  Magnan  *  a 
heinorrhacric  extravasation  as  laro-e  as  a  small  hazel-nut  was  found  in  the 
left  cerebral  peduncle,  at  its  insertion  into  the  optic  thalamus. 

The  prognosis  in  these  affections  is  very  poor  indeed.  Gowers  reports 
a  case  of  complete  recovery  after  the  employment  of  the  constant  galvanic 
current  for  a  number  of  months.  I  have  been  less  fortunate  in  my  expe- 
rience with  this  agent,  as  a  slight  amount  of  improvement  has  been  the 
utmost  which  1  have  been  able  to  obtain. 

Charcot  regards  the  prognosis  as  absolutely  unfavorable,  and  states 
that  the  choreiform  movements  only  terminate  with  the  patient's  life. 


Athetosis.  ^ 

Closely  allied,  and  by  many  considered  as  identical,  with  these  affec- 
tions is  the  disease  which  was  first  described  by  Hammond  under  the  title 
of  athetosis. 

The  main  features  of  this  affection  consist  of  slow  and  involuntary 
muscular  contractions,  occurring  especially  in  the  hands  and  feet,  and 
producing  rhythmical  alternations  of  flexion  and  extension  in  the  fingers 
and  toes.  The  disease  is  usually  unilateral  in  character  (the  right  side 
has  been  involved  in  most  cases),  but  in  some  instances,  both  sides  of  the 
body  have  been  affected.  The  majority  of  cases  have  been  associated 
with  other  cerebral  diseases,  such  as  %pilepsy,  dementia  paralytica,  loco- 
motor ataxia,  idiocy,  etc. 

The  following  is  the  history  of  an  interesting  case  of  this  affection, 
•which  is  probably  unique  from  the  fact  that  the  athetotic  symptoms  are 
the  sole  evidences  of  disease,  there  being  absolutely  no  other  manifesta- 
tions of  a  cerebral  affection. 

Case  VI. — G.  W.  L ,  ret.  18  years,  no  occupation.     The  patient's 

mother  died  of  phthisis,  the  father  and  other  mem.bers  of  the  family  are 
living  and  healthy.  According  to  the  father's  statement,  the  delivery  of 
the  patient  was  effected  normally,  though  it  occupied  a  somewhat  longer 
period  than  that  of  the  other  children;  no  resort  was  had  to  the  use  of 
the  forceps.  The  father  noticed  a  peculiarity  about  the  fingers  of  the 
right  hand  (he  was  unable  to  open  them  as  readily  as  upon  the  opposite 
side)  within  two  or  three  days  after  birth. 

Present  condition. — The  patient  is  a  very  well  nourished  and  bright  lad. 
His  education  has  been  neglected  on  account  of  his  infirmity,  but  his 
mental  powers  are  active  and  fully  equal  to  the  average  of  boys  in  his 
station  of  life.  The  special  senses  are  perfectly  normal.  The  right  side 
of  the  face  appears,  perhaps,  to  be  slightly  atrophied,  and  the  mouth  droops 
a  trifle  on  this  side.  When  the  patient  is  watched  and  when  he  talks 
or  smiles,  the  facial  muscles  upon  the  right  side,  especially  those  inserted 
into  the  angle  of  the  mouth,  are  in  an  almost  continual  state  of  clonic  and 
rather  slow  contraction. 

Upon  measurement,  it  is  found  that  the  length  of  the  arms  from  the 
acromion  process  to  the  end  <R  the  radius  is  equal  on  both  sides.  The 
right  arm  measures  8f  inches  i<i.  circumference,  the  left  arm,  9^  inches; 

^  Gaz.  med.  de  Paris,  1870. 


ciionEA.  15 

the  right  forearm  measures  8-J  inches;  tlie  left,  9^}  inches.  Tn  the  usual 
position  of  tlie  limb,  the  forearm  is  somewhat  flexed,  and  the  hand  and 
fingers  are  also  forcibly  flexed.  During  rest  the  muscles  of  the  arm  are 
quite  flaccid,  but  as  soon  as  the  patient  attempts  to  move  the  arm  in  any 
direction,  the  muscles  become  as  rigid  as  wood.  The  patient  usually 
grasps  the  affected  hand  with  the  other  in  order  to  keep  it  quiet. 

If  lie  sets  the  hand  free,  the  deltoid  of  the  affected  arm  immediately  con- 
tracts, drawing  the  limb  away  from  the  chest,  and  the  fingers  begin  to  twitch 
slowly,  the  most  common  form  of  movement  being  toward  more  marked 
flexion,  alternating  sometimes  with  slow  extension,  especially  of  the  2d 
and  od  phalanges. 

If  the  patient  is  directed  to  pick  up  anything  with  the  right  hand,  he 
must  first  extend  the  fingers  somewhat  with  the  left  and  then,  as  he  makes 
the  attempt,  the  fingers  become  hyperextended  and  widely  divergent,  so 
that  it  is  impossible  for  him  to  grasp  an  object. 

The  arm  can  be  moved  quite  freely  at  the  shoulder-joint,  though  not  as 
forcibly  as  on  the  sound  side;  passive  motion  at  this  joint  meets  with  slight 
resistance,  which  is  unattended  with  pain.  After  a  great  deal  of  effort,  the 
patient  becomes  able  to  flex  the  forearm  on  the  arm  after  it  has  been  ex- 
tended; when  extended  the  triceps  is  exceedingly  firm  and  contracted, 
the  biceps  not  to  the  same  degree.  While  the  patient  is  flexing  the  fore- 
arm the  biceps  becomes  flabby,  and  when  it  is  completely  flexed,  this  mus- 
cle is  entirely  flaccid.  The  forearm  cannot  be  voluntarily  extended  after 
it  is  flexed,  nor  can  the  hand  be  flexed  after  it  has  been  extended.  It  re- 
quires a  considerable  exertion  of  muscular  power  on  my  part  in  order  to 
vary  the  position  of  the  hand  from  any  in  which  it  may  be  at  the  time  of 
the  experiment.  The  continuous  movements  of  the  fingers,  when  not  sup^ 
ported  by  the  other  hand,  prevent  the  patient  from  employing  it  for  any 
purpose  whatever,  and  render  even  dressing  inconvenient  and  trouble- 
some. 

The  lower  limb  is  not  affected  to  the  same  extent  as  the  upper.  The 
right  thigh  measures  16^  inches,  the  left  18  inches;  the  right  calf  meas- 
ures 12  inches,  the  left  12|-  inches.  The  first  phalanges  of  the  foot  are 
flexed,  the  second  and  third  are  hyperextended.  When  the  patient  at- 
tempts to  walk,  the  gastrocnemii  and  solei  become  contracted  and  very 
rigid,  pulling  up  the  heel  so  that  he  is  forced  to  walk  on  the  front  part  of 
the  sole  of  the  foot;  at  the  same  time,  the  tibialis  anticus  contracts,  draw- 
ing up  the  inside  of  the  foot.  When  the  patient  is  directed  to  move  his 
toes,  slow  movements  of  extension  and  flexion,  similar  to  those  observed 
in  the  fingers,  though  of  course  not  so  marked,  become  evident.  Walk- 
ing is  not  very  much  interfered  with,  as  the  involuntary  movements  of 
the  toes  are  partially  restrained  by  the  shoe. 

Cutaneous  sensibility  and  the  electrical  reactions  of  the  ipuscles  are  nor- 
mal throughout  the  entire  body.  The  movements  of  the  muscles  continue 
unabated  during  sleep.  The  patient  is  perfectly  healthy  in  all  other  re- 
spects. The  treatment  consisted  in  the  application  of  the  faradic  current 
to  the  muscles  of  the  arm  (this  was  merely  done  to  retain  the  patient  un- 
der observation),  my  galvanic  battery  not  being  in  working  order.  To 
my  great  surprise,  the  abnormal  facial  movements  disappeared  almost  en- 
tirely in  the  course  of  5  to  6  weeks  (the  current  had  never  been  applied  to 
the  face),  and  the  violence  of  the  movements  of  the  fingers  was  also 
slightly  diminished.  I  then  applied  the  constant  galvanic  current  for  a 
couple  of  months,  but  without  producing  any  further  improvement.  The 
patient  then  passeU  out  of  my  observation. 


16  FUNCTIONAL    NERVOUS    DISEASES. 

Very  few  opportunities  liave  been  afforded  for  investigating  the  path- 
ological anatomy  of  this  affection,  and  I  have  only  been  able  to  obtain  re- 
cords of  five  post-mortems  upon  patients  suffering  from  athetosis.  In  one, 
the  brain  was  found  normal;  in  the  second,  two  small  spots  of  softening 
were  discovered  in  the  first  temporal  convolution;  in  the  third  case,  the 
patient  also  suffered  from  dementia  paralytica,  and  the  brain  presented  no 
evidences  of  a  localized  lesion;  in  the  fourth  case,  the  athetosis  occurred 
as  a  complication  of  locomotor  ataxia,  and  a  small  spot  of  softening  was 
found  at  the  posterior,  inferior,  and  outer  extremity  of  the  right  lenti- 
cular nucleus.  There  was  probably,  however,  no  connection  between 
this  lesion  and  the  athetosis,  since  the  latter  occurred  upon  both  sides  of 
the  bod}-.  The  fifth  case  is  of  great  interest  with  regard  to  the  light 
thrown  upon  the  relations  of  the  affection  to  post-hemiplegic  chorea,  and 
I  shall,  therefore,  present  a  short  abstract  of  the  case  as  reported  by  Dr. 
Sturges.* 

Case  VIL— H.  B ,  aet.  33  years;  when  three  years  old.  the  patient 

had  whooping-cough,  and  shortly  afterward  had  two  fits,  which  left  him 
paralyzed  on  the  left  side.  He  gradually  gained  power,  however,  in  the 
limb,  and,  at  the  age  of  ten  could  run  about  as  well  as  other  boys.  The 
athetosis  appeared  soon  after  the  fits,  and  gradually  increased  in  severity 
as  the  muscular  power  was  restored. 

The  movements  were  almost  exclusively  confined  to  the  left  upper 
limb,  and  were  continuous  and  involuntary.  When  the  hand  was  ex- 
tended with  the  palm  downward,  the  index  and  middle  fingers  were  slowly 
and  gradually  flexed.  The  thumb  was  also  adducted,  the  hand  was  then 
supinated,  the  fingers  again  extended,  and  the  thumb  abducted;  prona- 
tion of  the  hand  com]Dleted  the  cycle.  The  patient  could  slightly  control 
the  movements  by  a  great  effort  of  the  will;  the  hand  was  only  quiet 
during  sleep.  The  left  leg  occasionally  exhibited  a  somewhat  similar 
condition,  but  only  when  the  patient  was  tired  out  after  a  long  walk. 
Death  occurred  from  diarrhoea  and  exhaustion. 

Autojysy. — Brain:  right  hemisphere  distinctly  smaller  than  the  left; 
the  posterior  half  of  the  middle  and  inferior  frontal  convolutions,  and,  to 
a  slighter  extent,  the  superior  and  ascending  frontal  were  distinctly 
smaller  on  the  right  side  than  on  the  left;  the  parietal  convolutions  were 
also  smaller  on  the  right  side.  There  was  a  depression  on  the  anterior 
portion  of  the  temporo-sphenoidal  lobe,  about  one  inch  long;  there  was 
also  a  deep  depression  extending  backward  into  the  lobe,  about  three- 
fourths  of  an  inch  deep.  A  deep  excavation  was  found  between  the  anterior 
extremity  of  the  perforated  spot  and  the  convolutions  of  the  island  of  Reil, 
extending  backward  to  the  level  of  the  corpora  albicantia  and  forward  to 
the  anterior  surface  of  the  hemisphere.  The  sides  of  the  fissure  seemed 
to  have  been  in  apposition,  except  outside  the  perforated  spot,  where  the 
cavity  was  about  one-fourth  inch  wide;  its  roof  was  formed  by  radiating 
fibres  spreading  upward  from  the  pons.  Upon  opening  the  ventricles, 
almost  the  whole  of  that  portion  of  the  rig-ht  corpus  striatum  lying  in 
front  of  the  thalamus  appeared  to  be  destroyed;  the  posterior  portion  of 
the  nucleus  caudatus  was  unaffected.  A  small  portion  of  the  inner  part 
of  the  corpus  striatum  near  the  middle  appeared  intact,  but  the  whole 
of  the  gray  substance  was  destroyed.  The  optic  thalamus  seemed  to 
be  quite  healthy, 

*  Lancet,  March  15,  1879. 


CHOREA.  1 7 

These  post-mortem  investigations,  especially  the  one  last  mentioned, 
appear  to  me  to  disprove  conclusively  Hammond's  assumption  that  athe- 
tosis is  a  distinct  disease.'  The  latter  case  demonstrates  that,  in  some 
instances  at  least,  the  disease  merely  constitutes  a  peculiar  variety  of  post- 
hemiplegic chorea  (this  should  more  properly  be  called  symptomatic 
chorea).  1  have  also  distinct  recollection  of  a  case  of  post-hemiplegic 
chorea  in  a  girl,  xt.  9  years,  in  wliich  the  movements  of  the  fingers  were 
exactly  similar  to  those  described  by  Hammond  as  characteristic  of  athe- 
tosis. In  this  case,  the  patient,  while  suffering  from  intermittent  fever 
three  years  ago,  was  suddenly  seized  with  a  convulsion  which  took  the 
place  of  a  cliill.  The  child  was  found  to  be  hemiplegic  on  the  right  side 
on  the  following  morning.  As  the  power  began  to  return  to  the  affected 
arm,  the  athetoid  movements  made  their  appearance  and  have  continued 
ever  since. 

'  Leube  (Deutsch.  Arch.  f.  klin.  Med.,  Bd.  XXV.,  p.  242,  1880)  reports  a  case 
which  also  appears  to  show  that  athetosis  may,  in  some  instances,  be  a  mere  variety 
of  ordinary  chorea.  The  patient  in  question,  after  prolonged  exposure  to  wet.  devel- 
oped athetoid  movements  throughout  the  entire  body,  which  persisted  steadily  for 
four  years.  At  the  end  of  this  time  the  symptoms  changed  to  those  of  ordinary  severe 
chorea,  and  continued  as  such  during  the  entire  period  in  which  the  patient  remaiaed 
under  Leube's  observation. 


CHAPTEE  n. 

ETIOLOGY. 

Almost  all  writers  are  unanimous  in  the  opinion  that  sex  constitutes 
one  of  the  chief  predisposing  causes  of  chorea,  the  female  sex  presenting 
by  far  the  larger  proportion  of  cases  of  this  affection.  In  the  following 
statistics,  which  include  a  very  large  number  of  cases,  the  proportion  of 
males  to  females  is  382  to  1,053,  or  nearly  1  to  3: 

Females.  Males.  Total. 

See 393  138  531 

Rufz 138  51  189 

Hughes 240  69  309 

Steiner 40  12  52 

Pye-Smith 106  42  148 

Peacock 86  37  123 

Author 50  33  83 


1,053  382         1,435 

The  majority  of  cases  of  chorea  occur  from  the  fifth  to  fifteenth  years 
of  life,  as  is  shown  by  a  glance  at  the  following  tables: 

Below  5  yrs.  5 — 10  yrs.  10 — 15  yrs.  15 — 20  yrs.  Above  20  yrs. 

See 11  94  57  17                   12 

Steiner 4  46  6 

Pye-Smith..     5  62  44  19                     6 

Peacock ". .  22  51  14                    5 

Author 2  27  28  9                     5 

22  251  186  59  28 

In  very  rare  instances,  chorea  occurs  from  birth.  After  careful  ex- 
amination of  the  literature  of  the  question,  I  have  only  been  able  to  find 
the  histories  of  8  cases  of  congenital  chorea,  reported  by  Heller,*  Mayo,* 
Monod,  Spamer,^  Althaus,''  Fox,^  and  Richter  (2).°  In  Mayo's  case  the 
mother  had  been  extremely  nervous  for  a  period  of  two  months  after  a 
disgusting  object  had  been  thrown  upon  her  bosom  (while  she  was  four 
months  advanced  in  pregnancy).  In  Richter's  two  cases,  the  mothers  had 
been  very  much   frightened  shortly  before   confinement.     Spamer  men- 

'  Wien.  med.  Wschr.  19.  1876.  =  Outlines  of  Human  Pathology,  p.  170. 

2  Wien.  med.  Wschr.  52.  1876.  *  Diseases  of  the  Nervous  System,  1878. 

^  Brit.  Med.  Joum.,  1873,  No.  653. 

*  Sitzb.  d.  Dresden  Ges.  f.  Nat.  u.  Heilk.     Jan.  5,  1867. 


CHOREA.  19 

tions,  with  regard  to  his  case,  that  the  mother  had  been  very  nervous  and 
depressed  during  the  entire  period  of  pregnancy,  on  account  of  the  death 
of  one  of  her  children.  No  reference  is  made  in  the  reports  of  the  re- 
maining four  with  regard  to  the  probable  exciting  cause  of  the  disease. 

Chorea  is  very  infrequent  during  adult  life,  and  becomes  extremely 
rare  in  old  age.  When  it  occurs  after  the  age  of  fifty,  it  is  usually  at- 
tended with  some  mental  derangement,  especially  dementia.  Five  cases 
have  come  under  my  observation  which  developed  after  the  age  of  thirty- 
five  years,  one  of  which  was  complicated  with  insanity.  In  the  Lancet  for 
1878.  Dr.  R.  T.  Wright  reports  the  history  of  a  case  of  chorea  of  three 
years'  standing  in  a  man  seventy-eight  years  of  age. 

Heredity  exercisesbut  little  influence  upon  the  development  of  chorea, 
and  among  upward  of  ninety  cases  which  have  come  under  my  observation, 
I  have  not  been  able  to  obtain  a  single  instance  of  the  transmissibility 
of  the  predisposition  to  the  affection  from  parent  to  child.  Not  infre- 
quently, however,  it  is  found  that  one  of  the  parents,  usually  the  mother, 
suffers  from  nervousness  or  hysteria,  and,  in  a  considerable  number  of 
instances,  I  have  observed  that  one  or  more  of  the  brothers  or  sisters  of 
a  choreic  patient  were  subject  to  epilepsy  or  hysteria. 

Although  I  have  not  collected  any  comparative  statistics  on  this  ques- 
tion, I  am  nevertheless  convinced  that  chorea  develops  in  those  families 
in  whom  the  neuropathic  tendency  has  not  taken  strong  root,  while  in 
those  which  are  more  severely  affected,  more  serious  nervous  diseases, 
such  as  obstinate  neuralgias,  epilepsy,  insanity,  etc.,  make  their  appear- 
ance. In  not  a  few  cases,  however,  chorea  is  combined  with  epilepsy, 
especially  when  the  former  affection  has  become  chronic. 

Antemia  also  exerts  considerable  influence  as  a  predisposing  cause  of 
chorea,  but  its  importance  as  a  pathogenic  factor  must  not  be  overesti- 
mated. It  is  true  that  the  majority  of  patients  who  have  suffered  from 
chorea  for  any  length  of  time  present  symptoms  of  anaemia  (pallor  of 
face,  conjunctivae,  and  lips,  irritable  heart,  shortness  of  breath,  rapidly 
developing  sense  of  fatigue),  but  this  condition  is  then  secondary  to  the 
disturbed  sleep,  the  insufficient  supply  of  nutriment,  and  the  continual 
muscular  effort  to  which  the  patients  are  subjected.  Nevertheless,  we 
not  infrequently  meet  with  patients  of  a  very  nervous  temperament  who 
manifest  slight  choreiform  symptoms  as  soon  as  the  general  health,  for 
any  reason,  sinks  below  the  normal  standard. 

Onanism  is  also  looked  upon  as  an  active  predisposing  cause  of  chorea, 
as  it  is  of  so  many  other  nervous  affections.  I  have,  however,  only  been 
able  to  obtain  evidence  in  a  few  cases  of  the  sufficiency  of  this  cause  as  an 
agent  in  the  production  of  the  disease.  In  fact,  I  am  of  the  opinion  that 
the  baneful  effects  of  the  "secret  vice"  have  been  greatly  overestimated 
by  the  profession  at  large  as  well  as  by  the  laity.  The  habit  is  undoubt- 
edly practised  to  an  enormous  extent  among  children  of  both  sexes,  and 
if  its  potency  as  a  disease-producing  factor  were  as  great  as  it  is  claimed 
to  be  by  so  many  physicians,  chorea,  as  well  as  other  functional  neuroses, 
would  be  much  more  common  than  they  really  are.  While  I  therefore 
believe  that  excessive  onanism,  by  lowering  the  healthful  tone  of  the 
nervous  system,  may  prepare  the  way  for  the  more  ready  development  of 
nervous  affections,  I  doubt  whether  it  is  often  the  principal  agent  in  their 
production. 

The  exciting  causes  of  chorea  are  very  numerous.     Peacock'  gives  the 

1  St.  Thomas'  Hosp.  Rep.,  1877. 


20  FUNCTIONAL    NERVOUS    DISEASES. 

following  analysis  of  ninety-two  cases,  coming  under  his  own  observation, 
with  regard  to  causation: 

Not  ascertainable 23 

Fright 25 

Excitement 8 

Blows  on  head 5 

Driving  a  van  in  very  hot  Aveather 1 

Prolonged  lactation 1  or  2 

Pregnancy 3 

Suppression  of  the  catamenia 2  or  3 

Scarlatina 2 

Rheumatism 8  or  9 

Worms 3 

Among  the  ascertainable  causes,  therefore,  fright  holds  the  chief 
place.  As  a  rule,  the  development  of  the  chorea  follows  this  exciting 
cause  after  the  lapse  of  from  six  to  forty-eight  hours.  In  four  cases  under 
my  observation,  the  patients,  who  had  been  frightened  during  the  night 
by  an  alarm  of  fire  or  by  burglars,  awoke  the  following  morning  with  well- 
developed  choreiform  twitchings  of  the  entire  body.  In  one  instance,  the 
chorea  developed  immediately  after  the  exciting  cause.  The  patient,  an 
anemic  and  extremely  nervous  girl  of  ten,  was  suddenly  startled  last  Au- 
gust by  a  terrible  clap  of  thunder,  which  was  so  severe  that  it  was  the 
subject  of  town  talk  for  several  days.  The  guardian  of  the  patient,  a 
very  intelligent  young  lady,  assured  me  that  the  choreic  movements  de- 
veloped immediately  after  the  thunder-clap,  and  that  they  were  very  vio- 
lent from  the  beginning.  When  I  saw  the  girl  on  the  following  day,  the 
movements  were  so  violent  that  the  little  patient  M^as  unable  to  maintain 
her  seat,  and  could  only  walk  with  difficulty.  Violent  fits  of  anger,  or 
other  causes  of  excitement,  will  sometimes  act  in  the  same  manner  as  a 
severe  fright.  When  the  chorea  develops  one  or  two  weeks  after  pro- 
found mental  excitement,  it  is  extremely  doubtful  whether  this  can,  with 
propriety,  be  looked  upon  as  the  exciting  cause.  We  must  remember 
that  the  friends  of  the  patient  are  usually  anxious  to  aid  us  in  our  search 
for  the  origin  of  the  disease,  and  that  their  zeal  often  leads  them  to  mention, 
as  causes,  occurrences  which  long  antedated  the  development  of  the  mus- 
cular twitchings.  It  is,  therefore,  always  well,  when  told  that  the  chorea 
came  on  after  a  fright,  fall,  etc.,  to  enter  somewhat  into  the  details  of  the 
case,  and  judge  for  ourselves  whether  there  is  really  any  connection  be- 
tween the  two  occurrences.  Inattention  to  this  simple  rule  has  led  me 
astray  in  not  a  few  cases  of  this  as  well  as  of  other  diseases. 

Among  the  other  exciting  causes  of  a  mental  nature  we  must  mention 
imitation.  This,  however,  is  exceedingly  rare,  and  has  only  occurred 
once  in  the  cases  which  have  come  under  my  observation  (I  have  previ- 
ously referred  to  this  case  on  page  3).  Bricheteau  reports  a  very  inter- 
esting example  of  an  "  epidemic  "  of  chorea  which  developed  in  his  wards 
at  the  Hopital  Necker.  Within  a  week  after  the  admission  of  a  choreic 
patient  into  the  hospital,  eight  other  patients  (females)  occupying  the 
same  ward  became  affected  with  the  disease.  Its  further  spread  was  only 
prevented  by  isolating  the  choreic  patients. 

Rheumatism  constitutes  one  of  the  most  interesting  causes  of  chorea, 
both  on  account  of  the  differences  of  opinion  with  regard  to  its  importance 
and  also  on  account  of  its  relations  to  the  pathology  of  the  affection. 


CHOREA.  21 

The  opinions  of  different  authorities  vary  diametrically  with  regard  to 
this  question.  The  theory  of  its  intimate  relations  to  chorea  has  been 
especially  promulgated  by  English  and  French  writers.  M.  See  '  states 
that  one-half  of  the  entire  number  of  cases  of  chorea  are  caused  by  the 
rheumatic  poison.  Roger''  is  even  more  pronounced  in  his  views  concern- 
ing the  relations  of  rheumatism  and  chorea  than  the  preceding  author,  and 
thinks  that  the  coincidence  of  these  two  affections  is  as  much  evidence  of 
a  pathological  law  as  the  so  frequent  coexistence  of  endocarditis  and  rheu- 
matism. Among  104  cases  which  were  reported  in  Hughes'  and  Brown's 
paper  on  chorea  in  the  Gicy^s  Hospital  Reports,  for  1855,  and  which  were 
carefully  investigated  with  regard  to  the  previous  existence  of  rheumatism, 
only  fifteen  cases  were  found  in  which  the  latter  affection  had  not  been 
present,or  in  which  a  cardiac  murmur  was  not  audible.  Trousseau  also  be- 
lieves that  rheumatism  is  one  of  the  most  common  causes  of  chorea.  But 
numerous  statements  to  the  contrary  have  been  made  by  various  au- 
thorities. Steiner '  found  that  among  252  cases  under  his  observa- 
tion, a  history  of  previous  rheumatism  could  be  obtained  in  only  four. 
Octavius  Sturges  *  saw  only  five  positive  cases  of  acute  rheumatism,  among 
seventy-one  cases  of  chorea.  Among  forty  personal  cases  which  I  examined 
with  great  care  in  this  respect,  only  three  gave  a  history  of  previous 
rheumatism.  Among  these  three  patients,  two  presented  a  well-marked 
mitral  systolic  murmur,  and  in  the  third,  the  heart-sounds  were  normal. 

It  must  be  remembered,  in  estimating  the  importance  of  rheumatism 
as  an  etiolosrical  factor  in  chorea,  that  a  diaarnosis  of  the  former  disease  is 
frequently  made  on  insufficient  data.  The  cases  of  acute  rheumatism  in 
children  which  have  come  under  my  observation,  have  presented  exactly 
similar  symptoms  to  those  occurring  in  acute  rheumatism  in  the  adult. 
Not  infrequently,  however,  neuralgic  pains  in  the  joints,  muscular  rheu- 
matism in  the  neighborhood  of  the  joints  or  hyperaesthesia  of  the  skin, 
are  regarded,  in  children,  as  sufficient  evidence  of  rheumatism.  In  like 
manner  many  physicians  look  upon  a  basic  heart-murmur,  even  when  un- 
attended with  hypertrophy  of  the  organ  or  with  the  subjective  symptoms 
of  valvular  lesion  of  the  heart,  as  sufficient  evidence  of  endocarditis,  and 
presumably,  therefore,  of  antecedent  rheumatism.  In  such  cases,  the  his- 
tory of  previous  pains  in  the  limbs  is  regarded  as  ample  testimony  oi  the 
rheumatic  origin  of  the  endocarditis. 

Rilliet  has  also  referred  to  the  fact  that  chorea  rarely  appears  in  cer- 
tain localities  in  which  acute  articular  rheumatism  is  of  frequent  occur- 
rence, as,  for  instance,  in  Geneva. 

As  a  rule,  chorea,  when  connected  with  rheumatism,  develops  in  the 
latter  stages  of  this  affection  or  at  a  varying  interval  after  recovery.  In 
rare  instances,  however,  the  chorea  precedes  the  attack  of  rheumatism  in 
point  of  time.  Roger  *  mentions  an  extremely  interesting  case  occurring 
in  a  girl  set.  11^  years  who  suffered,  within  less  than  five  years,  from  six 
attacks  of  acute  articular  rheumatism  and  five  of  chorea,  hemiplegia  and 
endocarditis  also  developing  during  two  of  the  relapses. 

Chorea  is  also  said  to  be  sometimes  caused  by  reflex  irritation,  such 
as  the  presence  of  worms  in  the  intestinal  canal,  toothache  from  carious 
teeth,  amenorrhcea,  pregnancy,  irritation  of  cicatrices  in  various  parts  of 
the  body.     There  is  no  doubt  that  these  causes  may  sometimes  give  rise 

'  Mem.  de  TAcad.  Nat.  de  Med. ,  t.  xv.  '  Gaz.  med.  de  Paxis,  Mar.  7,  1868. 

3  Prag.  Vjschr.  1868.  ■*  Lancet,  p.  283,  1878. 

*  Arch,  gener. ,  vol.  ii. ,  p.  658. 


22  FUNCTION' AL    NERVOUS    DISEASES. 

to  the  disease,  although  the  existence  of  reflex  chorea  has  been  denied  by 
some  authorities.  Eulenburg  states  that  he  has,  on  several  occasions,  found 
the  disease,  when  due  to  dental  disorders,  disappear  after  the  extraction 
of  the  carious  teeth,  and  again  make  its  appearance  upon  the  development 
of  fresh  trouble  in  the  teeth.  The  case  of  Fann\^  M.,  which  we  described 
upon  page  8,  seems  to  show  that  chorea  is  sometimes  dependent  on  the 
sudden  abolition  of  the  menstrual  discharge,  as  the  chorea  appeared  soon 
after  the  development  of  the  amenorrhceic  condition,  and  no  other  cause 
could  be  ascertained. 

It  is  doubtful  whether  pregnancy  produces  chorea  from  the  reflex  irri- 
tation due  to  the  presence  of  the  foetus  in  utero,  or  from  the  aucemia  and 
hydrsemia  which  usually  exist  in  this  condition.  Judging,  however,  from 
the  action  of  pregnancy  in  the  development  of  other  neuroses,  I  should 
think  it  probable  that  chorea  gravidarum  is  attributable  to  reflex  irrita- 
tion. 

Finally,  we  must  consider  the  effects  of  syphilis  upon  the  development 
of  chorea.  Although  this  affection  is  such  a  frequent  cause  of  various 
nervous  diseases,  there  are  extremely  few  examples  on  record  of  cases  of 
chorea  which  may  be  attributed  to  its  agency.  I  have  only  been  able  to 
obtain  records  of  seven  cases,^  one  of  which,  however,  was  really  post-hemi- 
plegic  chorea,  a  consideration  of  which  has  been  previously  entered  upon. 

Of  these  seven  cases,  four  occurred  in  females  and  three  in  males.  Two 
developed  at  the  age  of  seven  years,  one  at  the  age  of  twelve,  and  the 
remainder  between  the  ag'es  of  twentv  and  thirtv-three  years.  Five 
recovered  completely  under  the  use  of  anti-syphilitic  remedies,  one  was 
unimproved,  and  one  proved  fatak 

It  is  extremely  difficult  to  determine  in  what  manner  the  syphilitic 
virus  produces  the  choreiform  movements.  In  all  probability  they  may 
be  attributed  to  disturbances  in  the  nutrition  either  of  the  cortical 
motor  centres  or  of  the  basal  ganglia  caused  by  the  changes  in  the  walls 
of  the  vessels  which  are  now  recognized  as  the  frequent  origin  of  syphili- 
tic cerebral  disturbances. 

In  very  rare  instances,  chorea  appears  to  be  due  to  malarial  influences, 
as  in  the  following  personal  case. 

Case  VIII. — Mrs.  Eliza  G.,  set.  26  years,  married  six  months;  her  pater- 
nal uncle  and  father's  first  cousin  were  insane;  the  patient  was  in  fair  health 
until  marriage  (six  months  ago),  but  since  then  very  marked  hj-sterical  man- 
ifestations have  developed.  Upon  vaginal  examination  the  hymen  is  found 
to  be  intact,  and  the  patient,  on  inquiry,  states  that  sexual  intercourse 
has  never  been  satisfactorily  consummated.  The  hysterical  symptoms 
were  undoubtedly  due  to  this  condition  of  the  genital  organs,  and  to  the 
nervous  irritability  produced  by  the  ungratified  sexual  desire.  For  the 
past  three  months  the  patient  has  been  suffering  from  muscular  twitchings 
which  were  chiefly  confined  to  the  right  side  (face,  arm,  and  leg),  but  were 
also  manifested  to  a  slighter  degree  on  the  left  side.  The  patient  and 
her  mother  are  positive  in  their  statement  that  the  choreiform  movements 
only  appeared  every  other  day  during  the  first  two  months.  Within  the 
last  month,  the  twitching  was  noticeable  every  day,  but  was  very  slight 
on  the  alternate  days,  so  that  distinct  periodicity  is  marked  even  at  the 

'  Zambaco :  Des  affections  nerveuses  sj'philitiques,  Paris,  1862.  PhUa.  Med.  Times, 
April  14,  1877.  Alison:  Amer.  Joum.  of  Med.  Sciences,  vol.  ii.,  1877.  Raymond: 
Etude,  etc.,  sur  rhenaichoree,  etc.,  Paris,  1876. 


cnoREA.  23 

present  time.  Upon  examination,  the  spleen  was  found  to  be  enlarged, 
but  there  were  no  other  evidences  of  malaria.  Acting  on  the  theory  that 
the  chorea  was  of  a  malarial  nature,  I  placed  the  patient  on  thirty-grain 
doses  of  quinine  daily  (November  19th),  vphich  was  sufficient  to  produce 
marked  cinchonisra.  On  November  27th  the  choreiform  movements  had  en- 
tirely disappeared,  and  did  not  return  while  the  patient  remained  under 
observation  (six  to  eight  weeks).  There  was  also  marked  improvement  as 
regards  the  severity  of  the  hysterical  symptoms,  but  I  attributed  this 
change  to  the  fact  that  the  patient,  at  my  advice,  lived  separately  from 
her  husband,  thus  removing,  in  part  at  least,  the  cause  of  the  disorder. 


CHAPTEK  ni. 

PATHOLOGICAL  ANATOMY. 

Although  a  great  deal  of  attention  has  been  devoted  to  this  branch 
of  our  topic  within  the  last  twenty  years,  especially  by  English  patholo- 
gists, there  is  still  considerable  room  for  further  investigation.  The  au- 
topsies which  were  made  in  the  early  part  of  this  century  are  almost 
entirely  valueless,  as  they  were  performed  before  the  modern  improved 
methods  of  pathological  and  histological  research  had  come  into  general 
vogue.  But  this  criticism  will  also  hold,  to  a  certain  extent,  with  regard 
to  the  autopsical  investigations  made  at  the  present  day.  Numerous 
cases  are  reported  in  the  journals  in  which  the  writer  has  felt  himself 
justified  in  declaring  the  nervous  centres  intact,  although  microscopical 
examination  has  been  entirely  omitted. 

The  opportunities  for  post-mortem  examinations  in  this  affection  are 
comparatively  rare  on  account  of  the  infrequency  of  a  fatal  termination 
(among  upward  of  ninety  cases  which  have  come  under  my  observation,  in 
only  one  did  a  fatal  result  follow),  and  it  is  therefore  to  be  hoped  that 
those  observers  who  are  enabled  to  make  such  investigations,  will  resort 
to  a  careful  nlicroscopical  and  macroscopical  examination  of  the  central 
nervous  system,  as  well  as  of  the  peripheral  nerves. 

Aitken  examined  the  specific  gravity  of  the  basal  ganglia  of  the  brain 
in  a  case  of  chorea,  and  found  that  that  of  the  corpus  striatum  and  optic 
thalamus  on  the  right  side  was  1-025,  and  on  the  left  side  I'OSl.  These 
figures  vary  considerably  from  those  furnished  by  Bucknill  for  these 
ganglia  in  healthy  brains  (1"036). 

Kirkes  *  reported  several  cases  of  fatal  chorea  in  which  he  found  endo- 
carditis present  upon  autopsy.  Small,  fine  granulations  were  present  upon 
the  valves  of  the  heart,  especially  upon  the  mitrals.  Numerous  observa- 
tions of  a  similar  character  have  been  made  by  other  observers,  and  even 
in  cases  in  which  no  symptoms  of  rheumatism  had  been  presented  by  the 
patient  during  life. 

Broadbent  °  mentions  the  following  case.  The  patient  was  a  young 
woman,  twenty-three  years  of  age,  who  began  to  manifest  a  change  in  dis- 
position two  years  previously.  Her  general  health  soon  became  impaired, 
and  of  late  it  was  noticed  that  the  patient's  skin  was  assuming  a  browner 
hue.  She  was  confined  to  her  bed  for  a  period  of  two  weeks  with  what 
was  called  a  "low  fever,"  and  upon  her  recovery  from  this  condition  it 
was  found  that  she  had  lost  the  perfect  control  over  the  movements  of  the 
left  arm.  Well-marked  choreiform  twitchings  soon  appeared  in  this 
member,  then  spread  to  the  left  leg,  and  finally  to  the  limbs  on  the  oppo- 
site side  of  the  body.  When  admitted  to  the  hospital,  the  patient  was 
very  feeble  and   presented  general  choreiform  movements,  which   were 

'  Med.  Gazette,  1850,  and  Med.  Times  and  Gazette,  1863. 
'^  Traus.  Lond.  Path.  Soc,  vol.  xiii.,  IbGl. 


CHOREA.  25 

most  marked  upon  the  left  side.  The  chorea  continued  until  death, 
which  occurred  ten  days  after  admission. 

Post-mortem. — We  will  merely  mention  the  appearances  presented  in 
the  nervous  system,  the  other  lesions  having  no  relation  to  the  chorea. 
The  brain  was  perfectly  healthy  in  appearance  and  consistence.  The 
spinal  cord  was  firm  and  healthy  except  at  the  posterior  surface  of  the 
dorsal  region,  two  inches  above  the  lumbar  enlargement.  In  this  sit- 
uation a  small  tumor  was  noticed,  which  was  at  first  supposed  to  spring 
from  the  surface  of  the  cord,  but,  upon  section,  was  found  to  originate 
from  the  interior. 

Tuckwell '  gives  the  following  results  of  the  post-mortem  examination 
in  a  boy  aet.  17  years,  who  suffered  from  acute  chorea,  which  had  become 
complicated  with  mania  and  proved  rapidly  fatal.  Autopsy. — Upon  the 
middle  of  the  upper  surface  of  the  right  cerebral  hemisphere  was  a  spot 
of  softening  which  appeared  to  be  limited  strictly  to  the  cortical  layers. 
A  similar  spot  was  found  upon  the  under  and  outer  aspect  of  the  posterior 
lobe  of  the  same  hemisphere,  but  in  this  situation  the  lesion  also  ex- 
tended a  certain  distance  into  the  white  matter.  Upon  carefully  tracing 
up  the  posterior  cerebral  artery,  an  embolus  with  a  secondary  thrombus 
was  found  in  one  of  the  branches  which  led  in  the  direction  of  the  softened 
spot.  A  spot  of  softening  of  considerable  size  was  also  found  in  the 
dorsal  region  of  the  spinal  cord,  together  with  a  small  embolus  in  one 
of  the  vessels  within  the  affected  district.  The  heart  appeared  healthy 
with  the  exception  of  the  auricular  aspect  of  the  mitral  valves,  which 
presented  a  row  of  small,  delicate  vegetations  of  recent  origin. 

In  the  "  Saint  Bartholomew's  Hospital  Reports,"  vol.  v.,  Tuckwell  men- 
tions the  following  interesting  post-mortem  results  in  a  fatal  case  of  cho- 
rea: The  brain  was  well  developed  and  presented  nothing  abnormal  in  the 
meninges  or  upon  the  surface.  Upon  tracing  out  the  posterior  cerebral 
artery,  and  thereby  displacing  the  middle  cerebral  lobe,  the  inferior  por- 
tion of  this  lobe  on  the  right  side  was  found  softened.  The  softening 
involved  the  deeper  layers  of  the  cortex,  and  more  especially  the  subja- 
cent white  substance;  it  also  extended  upward  into  the  neighborhood  of 
the  corpus  striatum  and  optic  thalamus.  The  basal  ganglia,  however,  ap- 
j>eared  to  be  normal.  The  corresponding  portions  of  the  left  hemisphere 
were  also  softened,  but  to  a  less  extent  than  on  the  right  side.  The  re- 
maining portions  of  the  brain  presented  a  remarkably  firm  and  healthy 
appearance. 

The  spinal  cord  appeared  to  be  normal  in  all  respects. 

Heart. — The  auricular  aspect  of  the  mitral  valves  showed  the  following 
changes:  a  line  of  numerous  bright,  clustering,  warty  vegetations,  some 
as  large  as  a  pin's  head,  others  barely  visible,  extended  in  a  sinuous  course 
all  along  the  free  margin  of  each  leaflet.  In  two  or  three  places,  the  lit- 
tle growths  hung  only  by  a  fine  pedicle  to  their  line  of  attachment. 

Wilson  Fox  ^  also  reports  a  case  of  chorea  with  cerebral  embolism. 
During  the  course  of  the  disease  the  patient  had  presented  a  mitral  mur- 
mur, but  no  history  of  previous  rheumatism  could  be  obtained.  Upon 
autopsy,  the  heart  was  healthy,  except  that  the  free  borders  of  both  flaps 
of  the  mitral  valves  were  thickly  covered  with  rough  granulations,  which 
were  apparently  of  recent  origin.  The  brain  appeared  perfectly  healthy 
to  the  naked  eye,  but  Bastian,  who  made  a  microscopical  examination  of 

'  Brit,  and  For.  Med.-Chir.  Rev.,  1867. 
"^  Trans.  Lond.  Path.  Soc,  xx.,  1869. 


26  FUNCTIONAL    KERVOUS    DISEASES. 

this  organ,  observed  plugging  of  some  of  the  blood-vessels  in  the  medulla 
oblongata. 

Magnan '  reports  the  follovring  case:  C.  J.,  aet.  73  years;  previous  his- 
tory unknown,  presents  choreiform  movements  of  the  right  arm  and  leg; 
talks  incoherently.  After  great  difficulty,  it  is  found  that  this  condition 
has  only  lasted  three  or  four  days.  No  accurate  data  can  be  obtained 
with  regard  to  sensation. 

Upon  the  day  after  admission  to  hospital,  the  movements  were  inces- 
sant; they  extended  to  the  neck  and  face,  but  only  involved  the  right  side. 
They  increased  during  excitement,  and  ceased  during  sleep.  Upon  the 
following  day  the  choreic  movements  had  increased  in  severity,  the  face 
was  grimacing  (to  the  right)  and  the  arm  and  leg  were  in  constant  mo- 
tion. At  1  p.  M.  the  patient  became  pale  and  then  cyanosed,  the  move- 
ments ceased,  and  death  occurred  suddenly  in  syncope. 

Autopsy. — The  cerebral  meninges  were  thickened,  opaline  in  places, 
and  were  readily  detached  from  the  convolutions.  The  convolutions  were 
yellowish  and  diminished  in  size.  The  vessels  at  the  base  were  athero- 
matous; the  ependyma  of  the  lateral  ventricles  was  thickened.  The  ^tat 
crible  was  visible  in  both  hemispheres,  especially  in  the  corpora  striata 
and  optic  thalami. 

An  incision  through  the  left  cerebral  peduncle,  at  its  insertion  into  the 
optic  thalamus,  showed  a  hemorrhagic  foyer  as  large  as  a  small  hazel-nut, 
composed  of  soft,  reddish  clots  of  recent  date;  the  adjacent  nerve-tissue 
was  torn  and  infiltrated  with  fluid.  The  pons  and  medulla  presented  no 
appreciable  change.  A  yellowish  patch  of  old  softening  was  found  upon 
the  inferior  surface  of  the  left  lobe  of  the  cerebellum. 

W.  Howship  Dickinson  *  gives  the  results  of  autopsical  examination 
in  seven  fatal  cases  of  chorea,  the  appearances  in  which  may  be  briefly 
summed  up  as  follows: 

Case  T. — Injection  of  all  the  vessels  of  the  brain  and  cord,  especially 
in  the  corpora  striata  and  dorsal  region  of  the  cord.  Hemorrhage  into 
the  central  canal  of  the  spinal  cord,  which  was  distended  by  serum. 

Case  II. — Similar  injection  of  the  brain,  superficial  hemorrhages  and 
exudation  around  the  arteries  of  the  corpus  striatum.  Injection  of  the 
spinal  cord. 

Case  III. — Injection  of  cerebral  vessels,  especially  around  the  optic 
thalamus.  Injection  of  the  cord  and  hemorrhages  into  the  gray  matter  of 
the  dorsal  and  lumbar  regions. 

Case  IV. — Injection  of  the  brain,  chiefly  venous,  and  of  the  corpora 
striata.  Injection  of  the  cord,  with  large  hemorrhage  into  the  cervical 
gray  matter. 

Case  V. — Venous  injection  of  the  brain,  especially  of  the  corpora 
striata;  arteries  in  the  convolutions  near  the  Sylvian  fissure  surrounded 
by  blood  crystals.     Injection  of  spinal  cord. 

Case  VI. — Recent  injection  of  the  structures  at  the  floor  of  the  lateral 
ventricles,  and  of  the  spinal  cord. 

Case  VII. — Spots  of  "  sclerosis  "  (simple  atrophic  degeneration)  in 
the  substantia  perforata  and  in  the  gray  matter  of  the  corpora  striata. 
Extensive  exudations  into  the  cord. 

The   heart  was   examined  in  six   of  these  seven  cases.     Vegetations 

'  Gaz.  med.,  Paris,  1870.  *  Med.-chir.  Trans.,  vol.  lix. 


CHOREA.  27 

upon  the  mitral  valves  were  only  found  absent  in  one  case  (a  widow,  jet. 
54  years). 

Elisclier  '  found  anatomical  changes  in  all  parts  of  the  nervous  system 
in  a  patient  suffering  from  chorea  gravidarum,  who  died  of  puerperal 
endometritis;  the  median  and  sciatic  nerves  (which  were  the  only  peri- 
pheral nerves  examined)  were  flattened  and  smaller  than  normal,  and  had, 
at  the  same  time,  assumed  a  firmer  consistence.  Microscopical  examina- 
tion showed  that  the  amount  of  interfibrillary  connective  tissue  was  greatly 
increased,  and  that  it  contained  a  large  number  of  spindle-shaped  nuclei. 
Numerous  small  extravasations  of  blood  were  visible  between  the  nerve- 
bundles.  In  some  of  the  nerve-fibres  the  sheath  of  Schwann  appeared 
cloudy,  in  others  it  presented  a  vitreous  appearance;  in  these  fibres,  the 
axis-cylinders  could  only  be  detected  with  difficulty. 

Spinal  cord. — The  walls  of  the  blood-vessels,  especially  the  tunica  ad- 
ventitia,  were  thickened  and  contained  numerous  nuclei.  The  central 
canal  contained  considerable  serum,  and  the  surrounding  connective  tissue 
was  firmer  and  more  abundant  than  usual.  The  four  principal  collections 
of  ganglion  cells  in  the  gray  matter  were  separated  from  one  another  by 
well-marked  bundles  of  newly  formed  fibrous  tissue,  which,  in  the  sub- 
stantia gelatinosa,  contained  large  numbers  of  nuclei.  The  ganglion 
cells  were  misshapen  and  did  not  stain  well  with  carmine.  The  nuclei  of 
these  cells  were  no  longer  visible. 

Brain. — The  vessels  of  the  basal  ganglia  presented  the  appearance  of 
fatty,  amyloid,  and  pigment  degeneration.  The  vessels  were  covered,  in 
certain  places,  with  granular  cells.  Especially  in  the  corpus  striatum. 
Elischer  attaches  no  importance,  however,  to  this  appearance,  as  he  ob- 
served similar  lesions  in  two  patients  who  had  died  of  tuberculosis  and  in- 
ternal hemorrhage.  The  small  vessels,  especially  in  the  convolutions,  con- 
tained numerous  emboli,  composed  of  red  and  white  globules.  The 
neuroglia  of  the  brain  was  increased  in  amount  and  firmness,  and  was 
strewn  with  large,  coarsely  granular  nuclei.  The  vessels  of  the  corpus 
striatum  were  surrounded  by  numerous  minute  deposits  of  a  rusty-brown 
pigment.  The  ganglion  cells  contained  such  a  large  amount  of  pigment 
that  the  protoplasm  appeared  to  be  entirely  destroyed  and  displaced;  some 
cells  contained  no  nuclei,  and  were  filled  with  fat  granules.  The  changes 
in  the  ganglion  cells  were  only  visible  in  the  basal  ganglia,  the  cerebellum 
and  cerebral  convolutions  being  normal. 

The  following  autopsy,  for  an  account  of  which  I  am  indebted  to  the 
kindness  of  Dr.  E.  A.  Maxwell,  Curator  to  Charity  Hospital,  was  held 
upon  a  patient  whom  I  had  observed  from  time  to  time,  for  a  period  cov- 
ering several  years.  The  patient  was  an  inmate  of  the  Epileptic  and 
Paralytic  Hospital  on  Blackwell's  Island. 

Case  IX. — Catherine  Eppersault,  aet.  78  years,  admitted  1869,  died 
November  8, 1878.  Patient  has  been  choreic  for  more  than  twenty  years. 
Nothing  is  known  about  her  previous  history  as  she  had  no  friends  and 
her  speech  was  so  much  impaired  that  it  was  impossible  to  get  a  history 
from  her.  Such  language  that^he  used,  and  which  could  be  understood,  was 
vile  and  profane.  The  choreic  movements  affected  the  face,  tongue,  trunk, 
and  extremities,  and  were  extremely  violent  in  character.  The  body  and 
limbs  underwent  the  most  grotesque  and   hideous  contortions,  the  facial 


»  Virch.  Arch.     Bd.  61,  p.  485,  and  Bd.  63,  p.  104. 


28  FUNCTIONAL    NERVOUS    DISEASES. 

muscles  were  in  continual  activity,  and  the  tongue  was  protruded  and  re- 
tracted with  considerable  force.  The  movements  were  very  much  in- 
creased in  violence  when  the  patient  was  watched.  She  was  unable  to 
use  a  knife  or  fork,  and  her  food  was  cut  up  for  her.  The  patient  was, 
however,  able  to  eat  with  a  spoon,  though  with  considerable  difficulty. 
She  was  able  to  drink  from  a  tumbler  by  holding  it  with  both  hands,  but 
was  unable  to  wash  her  face  or  dress  herself.  She  never  spoke  about 
friends  or  relations.  She  would  only  eat  at  meal  times,  and  if  food  were 
presented  to  her  between  meals,  she  would  throw  it  at  the  head  of  the 
person  offering  it.  She  would  not  permit  the  clergyman  or  visiting  ladies 
to  converse  with  her,  and  would  attempt  to  throw  things  at  them  or 
curse  them.  The  patient  could  walk  without  assistance  by  taking  a  step, 
resting  for  a  short  time,  and  then  taking  another.  As  a  rule,  however, 
she  helped  herself  by  holding  on  to  the  beds.  Upon  several  occasions, 
however,  I  have  seen  her  walk  rapidly  through  the  wards  with  an  irregular 
gait,  the  arms  swinging  violently  in  all  directions,  and  the  head  tossed  from 
side  to  side  by  the  violence  of  the  choreiform  movements  in  the  muscles 
of  the  neck.  She  would  rarely  leave  her  chair  except  to  go  to  the  closet. 
Even  while  sitting  in  her  chair,  the  body  and  limbs  underwent  violent 
contortions  so  that  she  retained  her  position  with  some  difficulty.  Dur- 
ing sleep  the  movements  ceased  entirely.  The  patient  would  never  take 
medicine  and  would  not  allow  anybody  to  go  near  her  except  another 
patient  in  the  same  ward.  During  the  last  month  she  had  been  gradually 
failing,  becoming  weak  and  anasmic.  Upon  several  occasions  she  fell  to 
the  floor,  and,  about  a  month  ago,  sustained  a  severe  contusion  of  the 
right  side,  face  and  eye.  She  never  complained  since  her  admission  to  the 
hospital,  but  groaned  occasionally  during  the  last  week.  The  patient  has 
been  failing  very  rapidly  for  the  last  two  or  three  days,  but  would  not 
take  to  her  bed;  was  found  dead  in  her  chair,  November  8,  1878. 

Autopsy. — Atrophy  of  the  ascending  frontal  and  parietal  convolutions 
upon  either  side;  sclerosis  of  the  medullary  substance  of  both  hemispheres 
(middle  third) ;  descending  degeneration  of  the  crura,  pons,  medulla,  and 
cord;  cardiac  hypertrophy;  cirrhosis  of  the  liver;  chronic  diffuse  nephritis. 

The  post-mortem  was  held  forty-six  hours  after  death.  Body  of  medium 
size,  emaciated,  rigor  mortis  present;  contusion  over  right  frontal  bone, 
slight  oedema  of  the  eyelids. 

Head. —  Calvarium  thin  and  the  bones  easily  cut  with  a  knife.  Dura 
mater  shows  a  pachymeningitis  of  the  falx  cerebri;  the  sinuses  normal. 
Pia  mater  normal  with  the  exception  of  marked  oedema,  which  is  especi- 
ally evident  over  the  paracentral  lobule  on  each  side,  corresponding  to  the 
atrophy  of  the  underlying  convolutions.  The  vessels  at  the  base  of  the 
brain  show  thickening  of  their  walls  (in  places)  from  atheroma  and  a  de- 
posit of  calcareous  plates.  The  lumen  of  the  affected  vessels  is  moder- 
ately narrowed,  but  all  are  pervious,  so  far  as  examined. 

The  pia  mater  can  be  everywhere  normally  stripped  from  the  convo- 
lutions. Convolutions. — The  ascending  frontal  and  parietal  convolutions 
upon  either  side  are  moderately  atrophied  from  their  lower  third  up  to 
the  longitudinal  fissure.  The  atrophy  is  most  marked  on  the  right  side, 
at  the  situation  of  the  paracentral  lobule.  Externally,  the  color  of  the 
atrophied  gyri  shows  nothing  different  from  that  of  the  unaffected  convo- 
lutions, but,  upon  vertical  section  their  outer  third  presents  a  bluish  gela- 
tinous appearance,  and  the  inner  two-thirds  are  of  a  deeper  yellow  and 
more  granular  appearance  than  elsewhere.  The  affected  convolutions  are 
not  abnormally  softened. 


CHOEEA.  29 

Lateral  ventricles. — The  epend yma  is  thickened  and  presents  granula- 
tions upon  its  surface;  upon  the  right  side  over  the  corpus  striatum  this 
thickening  is  most  marked  and  corresponds  to  evident  atrophy  of  the 
interventricular  nucleus.  The  third  and  fourth  ventricles  show  nothing 
abnormal.  There  is  no  marked  dilatation  of,  or  increase  of  fluid  in  the 
ventricles.  On  section  of  the  brain  substance,  the  white  matter  is  found 
to  be  sclerosed  in  the  middle  third  of  each  hemisphere  and  extending 
somewhat  beyond  this  boundary  anteriorly.  The  sclerotic  portions  are 
tough  and  leathery  to  the  feel,  and  have  a  pinkish  blue  or  mother-of-pearl 
color.  There  is  a  symmetrical  spot  of  white  softening  in  the  middle  of 
the  outer  segment  of  each  lenticular  nucleus.  With  the  exception  of 
this  softening,  and  of  the  previously  mentioned  atrophy  of  the  right  in- 
terventricular nucleus,  the  basal  ganglia  are  normal.  The  crura  cerebri 
are  about  equal  in  size;  upon  transverse  section,  each  shows  central 
atrophy,  which  is  most  marked  on  the  right  side,  with  slightly  yellowish 
discoloration  of  the  white  fibres  bordering  on  the  locus  niger,  and  trans- 
formation of  the  normal  black  pigmentation  of  the  latter  to  a  dull  yellow- 
ish brown. 

Pons  varolii. — Upon  inspection,  the  lateral  halves  appear  to  be  of 
equal  size,  but  on  transverse  section  the  bundles  of  longitudinal  fibres  of 
the  right  side  are  scarcely  more  than  half  the  size  of  those  on  the  left. 

Medulla  oblongata. — There  are  no  marked  changes  to  the  naked  eye. 

Spinal  cord.- — This  exhibits  a  descending  degeneration  which,  to  gross 
appearances,  disappears  in  the  lumbar  region,  and  is  throughout  most 
marked  in  the  left  half  of  the  cord.  The  meninges  of  the  cord  are  nor- 
mal. 

Thorax. — The  sternum  fractures  upon  the  application  of  the  slightest 
force.  Several  ribs  are  fractured  and,  at  the  corresponding  portions  of 
the  costal  pleura  there  are  evidences  of  localized  pleurisy  and  subpleural 
hemorrhages.     Lungs  exhibit  emphysema  and  bronchitis. 

Heart. — Hypertrophied,  especially  the  left  ventricle. 

Aorta. — Dilated  and  atheromatous,  with  calcareous  plates. 

Abdomen. — Liver,  markedly  cirrhotic.  I^idneys. — Atrophied,  the  cor- 
tex fatty  and  filled  with  cysts  (chronic  diffuse  nephritis). 

The  above  mentioned  cases  will  suffice  to  furnish  an  idea  of  the  variety 
of  anatomical  lesions  which  have  been  found  present  in  chorea. 

"We  must  not  forget,  however,  that  a  considerable  number  of  cases 
have  been  reported  by  competent  and  careful  observers,  in  which  no 
material  lesions  of  the  nervous  system  were  found  either  upon  macrosco- 
pical  or  microscopical  examination. 


CHAPTEE  ly. 

PATHOLOGY. 

Even  at  the  present  day,  opinions  vary  as  to  the  cerebral  or  spinal 
origin  of  chorea.  The  chief  arguments  in  favor  of  the  spinal  charac- 
ter of  the  affection  have  been  advanced  by  French  physiologists,  espe- 
cially Chauveau,  Longet,  Carville  and  Bert,  Legros  and  Onimus. 

Chauveau '  experimented  upon  dogs  who  were  suffering  from  general 
choreiform  movements,  by  dividing  the  spinal  cord  immediately  below  the 
medulla  oblongata.  He  found  that  the  chorea  nevertheless  persisted  until 
the  death  of  the  animal  with  the  same  degree  of  severity.  If  the  spinal 
cord  was  divided,  however,  through  the  dorsal  region,  the  choreiform 
movements  immediately  ceased  in  the  tail  and  posterior  limbs,  but  re- 
mained unaffected  in  the  anterior  limbs. 

The  experiments  of  Longet,  Carville  and  Bert,  were  merely  confirma- 
tory of  the  results  obtained  by  Chauveau. 

Legros  and  Onimus^  made  more  extended  investigations  concerning 
this  question.  Like  the  authors  previously  mentioned,  they  also  found 
that  section  of  the  spinal  cord  immediately  below  the  medulla  oblongata 
did  not  diminish  the  violence  of  the  choreiform  movements,  if  artificial 
respiration  were  maintained.  If  the  spinal  cord  was  laid  bare  by  remov- 
ing the  vertebral  arches,  and  the  posterior  columns  of  the  cord  were  irri- 
tated with  the  end  of  a  scalpel,  the  choreiform  movements  were  exagge- 
rated to  an  enormous  extent.  If  the  cord  were  cooled  by  means  of  a  cur- 
rent of  air,  the  movements  disappeared  when  the  previous  temperature 
of  the  cord  was  restored  by  pouring  warm  water  upon  it.  The  move- 
ments were  uninfluenced  by  excision  of  the  posterior  roots  of  the  spinal 
nerves,  but  were  diminished  by  a  partial  incision  through  the  posterior 
white  columns  and  posterior  horns  of  gray  matter.  When  a  deep  incision 
was  made  through  these  regions,  the  choreiform  movements  were  entirely 
abolished. 

Legros  and  Onimus  think  they  are  justified  in  concluding  from  these 
experiments  that  the  morbid  process  in  chorea  is  situated  in  the  cells  of 
the  posterior  gray  horns,  or  in  the  fibres  wliich  connect  these  cells  with 
the  large  motor-cells  of  the  anterior  horns. 

These  experiments  appear  to  us  neither  to  prove  nor  disprove  the  spi- 
nal character  of  chorea  in  the  human  subject.  Apart  from  the  general 
suspicion  which  justly  attaches  to  the  drawing  of  conclusions  concerning 
functional  disorders  in  man  from  the  results  of  experiments  in  animals,  it 
is  quite  positive  that  the  chorea  of  dogs  is  an  entirely  different  disease 
from  the  similar  affection  in  man.  This,  of  course,  invalidates  all  con- 
clusions which  are  drawn  concerning  the  latter  from  the  morbid  appear- 
ances presented  in  the  former. 

A  review  of  the  pathological  anatomy  of  the  affection,  as  described  in 

'  Arch.  gen.  de  med.,  1866.  =  Comptes  rend.,  LX.,  1870. 


CHOREA.  31 

the  last  chapter,  teaches  us  that  the  lesions  of  chorea  have  been  found 
both  in  the  brain  and  spinal  cord,  and,  as  Elischer's  results  appear  to  in- 
dicate, in  the  peripheral  nervous  system  as  well.  In  numerous  cases,  on 
the  other  hand,  the  entire  nervous  system  has  been  found  intact.  It  is 
evident,  therefore,  that  pathological  anatomy  cannot  thoroughly  explain 
the  pathology  of  the  affection,  and  we  must  resort  for  further  light  to  the 
clinical  history  of  the  disease.  In  fact,  it  appears  to  us  that  undue  im- 
portance has  been  hitherto  attached  to  anatomical  investigations  in  the 
study  of  the  pathology  of  functional  diseases  of  the  nervous  system,  and 
too  little  to  the  clinical  symptoms  of  these  diseases  and  to  their  etiologi- 
cal relations. 

The  rapid  and  brilliant  development  of  pathological  anatomy  within 
the  last  twenty-five  years  has  laid  such  a  strong  hold  upon  the  minds  of 
medical  men  and  upon  their  habits  of  thought,  that  they  are  apt  to  rusli 
to  the  conclusion  that  the  presence  of  a  certain  anatomical  lesion  in  any 
disease  is  conclusive  evidence  that  such  lesion  constitutes  the  real  cause 
of  the  affection,  and  to  draw  a  hasty  generalization  from  very  meagre  data. 
In  no  department  of  medicine  is  this  more  marked  than  in  diseases  of  the 
nervous  system,  and  not  a  small  proportion  of  the  investigations  now 
being  carried  on  in  this  field  will  result  in  overturning  certain  of  the  theo- 
ries to  which  credence  has  been  hastily  and  incautiously  given. 

In  the  first  place,  the  weight  of  evidence  appears  to  us  to  be  over- 
whelmingly in  favor  of  the  cerebral  character  of  the  affection.  The  fact 
that  hemichorea  is  sometimes  combined  with  hemianesthesia,  and  that  the 
latter  symptom  is  always  observed  upon  the  same  side  as  the  choreiform 
movements,  is  proof  positive  that  the  lesion  is  cerebral  in  its  origin.  If 
it  were  of  a  spinal  nature,  the  decussation  of  the  sensory  fibres  in  the 
cord  would  cause  the  appearance  of  the  sensory  symptoms  upon  the  side 
opposite  to  the  motor  disturbances. 

Another  important  argument  in  this  particular  is  the  fact  that  mental 
disturbances  are  so  common  in  the  affection  under  consideration.  In  all 
the  cases  which  have  come  under  my  observation,  there  was  at  least  some 
change  in  the  disposition  of  the  patient,  consisting  of  irritability,  defi- 
cient memory,  or  obstinacy.  As  we  have  further  shown  in  the  chapter 
on  the  clinical  history  of  the  disease,  more  marked  mental  disturbances, 
advancing  even  to  insanity,  are  not  very  infrequent. 

Chorea,  also,  may  occur  in  one  member  of  a  family,  others  of  whom 
present  epilepsy  or  insanity,  or  the  chorea  may  alternate  in  the  same  pa- 
tient with  either  of  these  affections,  i.  e.,  the  hereditary  neuropathic  ten- 
dency may,  in  one  case,  involve  one  portion  of  the  brain,  giving  rise  to 
insanity,  in  a  second,  affect  another  part  causing  epilepsy,  and,  in  a  third, 
produce  chorea. 

Furthermore,  chorea  may  develop  during  the  course  of  well-defined 
cerebral  diseases,  such  as  hemorrhages,  tumors,  meningitis.  In  the  rare 
cases  of  praehemiplegic  chorea,  the  choreiform  movements  appear  as  the 
precursors  of  the  cerebral  affection,  and  are  undoubtedly  due  to  the  initial 
development  of  the  cerebral  lesion. 

Finally,  movements  of  the  facial  muscles,  which  are  supplied  by  cra- 
nial nerves,  are  noticed  in  the  vast  majority  of  cases  of  chorea,  a  symp- 
tom which  is  inexplicable  on  the  theory  of  the  spinal  origin  of  the  disease. 

But,  although  there  is  good  ground  for  the  belief  that  chorea  is  a  cer- 
ebral affection,  the  theories  with  regard  to  the  nature  and  position,  of  the 
lesion  are  extremely  various. 

See,  struck  by  the  frequent  coincidence  of  chorea  and  rheumatism  or 


32  FUNCTIONAL    NERVOUS   DISEASES. 

endocarditis,  regarded  both  processes  as  very  closely  related,  but  gave  no 
very  satisfactory  account  of  the  connection  between  them. 

Some  years  later,  Roger  advocated  the  doctrine  that  chorea,  rheuma- 
tism, and  endocarditis  are  so  many  manifestations  of  one  diathesis,  the 
difference  in  the  clinical  history  of  the  three  affections  depending  merely 
upon  the  organ  affected.  But  this  sweeping  statement  is  amply  dis- 
proved by  the  results  of  the  statistics  which  we  have  collected  in  the 
chapter  on  etiology,  and  also  by  our  own  experience.  Thus,  in  upward 
of  ninety  cases  which  have  come  under  my  observation,  in  only  three  were 
there  any  evidences  of  rheumatism. 

Nevertheless,  the  results  of  autopsical  examinations  have  at  least 
proven  the  frequent  coexistence  of  chorea  and  endocarditis.  Kirkes  first 
propounded  the  "  embolismic  "  theory  of  the  connection  existing  between 
these  two  affections.  He  considered  the  theory  of  a  rheumatic  dia- 
thesis as  the  causal  factor  of  rheumatic  arthritis,  endocarditis,  and  chorea 
unsatisfactory,  because  the  two  latter  diseases  are  often  associated, 
although  no  trace  of  previous  rheumatism  can  be'  discovered.  He  regards 
it  as  very  probable  that  chorea  is  due  to  removal  of  some  of  the  fibrinous 
particles  from  the  valves  of  the  heart  and  to  the  disturbances  created  in 
the  nerve-centres  by  the  impaction  of  such  particles  in  the  cerebral  ves- 
sels. At  a  later  period  Broadbent,  in  an  article  read  before  the  London 
Medical  Society,  narrowed  down  the  doctrine  more  closely,  by  stating 
that  the  chief  cause  of  chorea  is  capillary  embolism  of  the  basal  ganglia 
(corpus  striatum  and  optic  thalamus)  and  of  the  structures  in  their  im- 
mediate vicinity.  This  theory  was  also  strengthened  by  the  investi- 
gations of  numerous  English  observers,  notably  Hughlings  Jackson, 
Tuckwell,  and  Ogle. 

W.  Howship  Dickinson,  although  he  acknowledges  the  close  relation- 
ship of  chorea  and  endocarditis,  thinks  that  the  latter  affection  is  a  sec- 
ondary process,  due  to  the  choreiform  movements  of  the  papillary  mus- 
cles of  the  heart.  As  we  have  previously  stated  in  our  remarks  on  the 
clinical  history  of  the  affection,  it  is  extremely  problematical  whether  the 
muscular  tissue  of  the  heart  is  ever  the  seat  of  choreiform  contractions. 
But,  even  if  this  condition  could  be  proven,  we  are  unable  to  understand 
in  what  manner  it  would  lead  to  inflammation  of  the  endocardium. 

Although  the  embolismic  theory  of  chorea  is  very  plausible  and  fasci- 
nating, there  are,  in  our  opinion,  weighty  objections  to  be  urged  against 
its  acceptance. 

In  the  first  place,  in  ordinary  cerebral  embolism,  the  embolismic  par- 
ticles, from  causes  which  it  is  not  necessary  to  enter  into  in  this  place,  are 
usually  distributed  to  the  vessels  on  the  left  side  of  the  brain. 

Ottomar  Gelpke  *  denies  the  truth  of  this  statement  to  the  extent  to 
which  it  is  generally  believed,  and  finds  from  an  analysis  of  131  cases  of 
cerebral  embolism  that  sixty-four  occurred  upon  the  left  side,  fifty-four 
on  the  right,  and  thirteen  on  both  sides,  thus  rendering  the  proportion 
on  the  two  sides  almost  equal.  Bertin,^  however,  found  thirty-six  cases 
of  ebmolism  on  the  left  side  of  the  brain,  and  only  nine  on  the  right  side. 
Gerhardt '  observed  the  embolus  thirty-five  times  in  the  left  middle  cere- 
bral artery,  and  sixteen  times  in  the  right.  Although  I  have  been  una- 
ble to  obtain  any  statistics  on  the  subject,  I  am  positive  that,  among  a 


'  Arch.  d.  Heilk.  1875.  -  fitude  critique  de  Tembolie. 

»  Wuerzb.  med.  Zschr.  186a. 


CHOREA.  83 

large  number  of  cases  of  cerebral  embolism  which  I  have  had  the  oppor- 
tunity of  observing  post-mortem  in  the  dead-house  of  Bellevue  Hospital, 
very  few  cases  have  occurred  upon  the  right  side  of  the  brain.  Dr.  Jane- 
way  has  also  called  my  attention  to  the  fact  that  the  ordinary  statistics 
with  regard  to  the  relative  frequency  of  right  and  left  cerebral  embolism 
are  unreliable,  because,  from  the  comparative  rarity  of  right-sided  embo- 
lism cases  of  this  nature  are  apt  to  be  published,  while  left-sided  embolism 
is  not  considered,  as  a  rule,  worthy  of  publication. 

In  the  second  place,  the  clinical  history  of  chorea  differs  from  that  of 
cerebral  embolism.  The  paralyses  which  occur  in  the  former,  almost  in- 
variably recover  very  rapidly,  and  do  not  come  on  as  suddenly  as  those 
dependent  upon  embolism.  While  a  choreal  paralysis  may  recover  com- 
pletely within  a  couple  of  weeks,  a  case  of  equally  severe  paralysis  from 
cerebral  embolism  will  occupy  several  months  in  recovery,  and  even  then, 
as  a  rule,  some  paresis  of  the  affected  limbs  is  still  perceptible. 

Furthermore,  while  true  aphasia  not  infrequently  occurs  in  cerebral 
embolism,  this  symptom  does  not  develop  in  chorea.  The  disorder  of 
speech  which  occurs  so  frequently  in  the  latter  disease  is  due  to  an  exten- 
sion of  the  affection  to  the  muscles  of  phonation,  and  is  not  of  a  cere- 
bral nature,  properly  speaking,  in  the  same  sense  that  aphasia  is. 

Finally,  the  chief  argument,  perhaps,  against  the  acceptance  of  the 
embolismic  theory  of  chorea  lies  in  the  fact  that  the  lesion  is  found  so 
seldom  by  pathologists  although  search  has  been  carefully  made. 

The  tlieory  of  capillary  embolism  restricts  the  lesion  of  chorea  to  the 
basal  ganglia^  since  the  collateral  circulation  is  so  free  in  the  cortex  of 
the  brain  that  plugging  of  a  few  capillaries  would  produce  no  evil  effects 
upon  the  nutrition  of  the  nerve-structures  in  that  locality.  But  a  lesion 
of  the  motor  and  sensory  basal  ganglia  will  not  produce  the  mental  dis- 
turbances which,  as  we  again  insist,  form  such  an  integral  part  of  the 
clinical  history  of  the  affection. 

Somewhat  similar  to  the  embolismic  theory  of  chorea  is  Bastian's 
theory  of  capillary  thrombosis,  which  he  formulates  as  follows:  chorea  is 
due  to  an  altered  and  often  antemic  state  of  the  blood  which  chiefly  acts 
upon  the  corpora  striata  and  surrounding  parts,  causing  the  tissue  ele- 
ments to  become  "irritated;"  congestion  then  develops  as  a  neces- 
sary consequence.  If  the  irritation  continues  for  a  certain  length  of  time, 
the  disturbed  action  outside  of  the  vessels  is  communicated  to  the  tissue 
elements  within  them,  the  white  corpuscles  therefore  begin  to  adhere  to 
the  walls  of  the  small  vessels,  so  that  partial  obstructions  may  be  pro- 
duced, which  are,  perhaps,  afterward  rendered  complete  by  the  separation 
of  fibrine  or  allied  products.  In  exceptional  cases  (observed  by  Aitken 
and  Tuckvvell),  small  foci  of  softening  result  from  these  processes. 

Apart  from  the  slight  amount  of  support  which  this  theory  receives 
from  post-mortem  investigations,  the  same  objections  apply  to  it  as  were 
advanced  in  opposition  to  the  doctrine  of  the  embolismic  origin  of  chorea. 
Furthermore,  neither  of  these  theories  is  capable  of  explaining^  the 
numerous  class  of  cases  in  which  the  disease  evidently  results  from  fright, 
from  reflex  causes,  or  from  imitation. 

It  seems  to  us  that  very  little  aid  can  be  derived  from  pathological 
anatomy  in  determining  the  situation  of  the  lesion  in  chorea.  The  vast 
majority  of  patients  recover  from  this  disease  without  presenting  any 
severe  symptoms,  and  it  is  therefore  highly  improbable  that  a  serious  an- 
atomical brain  lesion  was  present.  As  shown  in  the  chapter  on  patho- 
logical anatomv,  chorea  may  accompanv  various  cerebral  lesions,  but  these 
3" 


34  FUNCTIONAL   KEEVOFS   DISEASES. 

should  then  be  regarded  rather  as  complications  than  as  essential  features 
of  the  disease. 

The  symptomatology  of  chorea  may  be  broadly  considered  as  consist- 
ing of  mental  disturbances  (irritability,  loss  of  memory,  perhaps  mania, 
etc.),  and  motor  disorders  (muscular  twitchings,  certain  amount  of  paresis). 

These  symptoms  could  be  readily  explained  by  a  lesion  of  the  cerebral 
cortex  in  the  neighborhood  of  Hitzig's  motor  centres  and  the  adjacent 
parts  of  the  frontal  convolutions.  Like  all  the  functional  neuroses,  chorea 
is  an  evidence  of  low  tone  of  the  nervous  system,  and  we  may  accordingly 
regard  the  cortical  disturbance  either  as  the  result  of  anaemia  in  the  parts 
affected,  or  of  malnutrition  or  exhaustion  of  the  ganglion  cells  in  the 
convolutions.  As  a  matter  of  course  we  can  offer  no  demonstrable  proof 
of  the  correctness  of  this  view,  but  it  appears  to  tally  best  with  the  re- 
sults of  clinical  observation. 

To  our  thinking,  no  theory  can  be  correct  which  does  not  explain  the 
general  run  of  cases,  and  not  alone  those  which  are  attended  with  excep- 
tional symptoms  or  terminate  fatally.  The  theory  of  malnutrition  of  the 
cortical  ganglion  cells,  either  as  the  result  of  anaemia  or  of  a  direct  effect 
upon  the  nerve-cells,  such  as  is  known  to  occur  at  times  as  the  result  of 
fright,  appears  to  us  to  be  capable  of  explaining  the  large  majority  of 
cases  of  the  disease. 

In  this  connection  we  desire  to  call  attention  to  the  views  expressed 
by  Sturges  '  who  has  written  some  admirable  articles  on  the  disease 
under  consideration.  This  author  believes,  "  that  the  pathology  of  an 
affection  like  chorea  is  to  be  sought  in  the  natural  endowments  of  the  in- 
dividual; that  it  comes  to  be  a  child's  disease  because  those  elements  out 
of  which  it  is  evolved  are  especially  prominent  in  early  life;  that  child- 
hood not  only  p7'edisposes  to  chorea,  but  has  also  the  material  which  is 
efficient  to  produce  it."  He  points  out  the  identity  of  the  movements 
of  restlessness  in  a  shy  child  when  embarrassed,  with  those  observed  in 
chorea,  and  believes  that  the  latter  may  grow  directly  out  of  the  former 
as  the  result  of  fright,  pain,  etc. 

'  Med.  Times  and  Gazette,  April  28,  1877. 


CHAPTER  y. 

DIAGNOSIS  AND  PROGNOSIS. 

The  clinical  history  of  chorea  minor  is  so  sharply  defined  that  it  is  very 
rarely  mistaken  for  other  diseases.  In  children,  as  well  as  in  adults, 
care  must  be  taken  to  differentiate  it  from  post-hemiplegic  chorea.  An 
inquiry  into  the  previous  history  of  the  patient  will  soon  dispel  any 
doubts  which  may  exist  with  regard  to  the  diagnosis.  The  post-hemi- 
plegic affection  is  unilateral,  and,  as  a  rule,  when  the  movements  have 
begun  in  the  first  five  or  six  years  of  life,  the  limbs  of  the  affected  side  are 
atrophied  in  all  directions;  this  does  not  hold  good,  however,  with  regard  to 
post-hemiplegic  chorea  of  adult  life.  The  movements  in  the  post-hemiplegic 
affection  generally  subside  entirely,  when  the  patient  is  not  performing 
any  voluntary  movements,  and  are  usually  not  so  rapid  or  sudden  as  those 
of  ordinary  chorea.  After  the  disease  has  lasted  for  a  long  time,  a  mere 
examination  of  the  patient  may  be  insufficient  to  determine  the  true 
nature  of  the  affection,  as  the  original  loss  of  power  in  the  limbs  may  have 
disappeared,  leaving  only  the  choreic  movements. 

The  nature  of  pre-hemiplegic  chorea  (which  is  an  extremely  rare 
affection)  will  only  be  cleared  up  by  the  further  history  of  the  case,  unless 
apoplectic  symptoms  develop  from  the  onset  and  accompany  the  chorei- 
form movements.  These  movements  may  continue,  however,  for  several 
days  before  the  development  of  hemiplegia,  etc.,  warns  us  of  the  true 
character  of  the  affection  with  which  we  have  to  deal. 

In  rare  instances,  it  will  become  necessary  to  differentiate  chorea  from 
cerebro-spinal  sclerosis.  As  a  rule  this  can  be  readily  done  from  a  con- 
sideration of  the  clinical  history.  In  multiple  sclerosis,  the  patients  suf- 
fer usually  from  marked  sensory  disturbances  (pain,  anaesthesia  in  the 
limbs),  from  paresis  or  contracture  of  muscles,  bladder  symptoms,  pupil- 
lary phenomena,  cerebral  disturbances.  Occasionally,  however,  the  motor 
disorders  constitute  the  chief  symptom  (perhaps  for  a  certain  length  of 
time  the  only  discoverable  one),  and  we  must  therefore  directly  compare 
the  motor  phenomena  of  chorea  and  sclerosis. 

As  a  rule,  the  movements  of  chorea  develop  independently  of  any 
voluntary  effort  on  the  part  of  the  patient;  the  latter  may  be  sitting  per- 
fectly quiet  when  suddenly  the  fingers  twitch,  the  muscles  of  the  face  con- 
tract, or  the  tongue  is  protruded  from  the  mouth.  In  cerebro-spinal 
sclerosis,  however,  the  irregular  movements  are  not  evident  unless  the 
patient    makes    a    voluntary    effort  ^    and    the    greater    the    will-power 

'  Charcot  was  the  first  to  call  attention  to  this  point,  and  lays  it  down  as  an  ab- 
solute rule.  That  exceptions  do  occur,  is  proven  by  a  case  which  I  observed  in  Dr. 
Janeway's  practice,  and  in  which  the  autopsy  showed  the  nature  of  the  aflEection. 


36  FUISrCTIOI^AL    NERVOUS    DISEASES. 

exerted  the  more  violent  do  the  movements  become.  Another  point 
of  contrast  between  the  two  affections  consists  in  the  fact  that,  in 
cerebro-spinal  sclerosis,  the  general  direction  of  the  intended  movement  is 
maintained  throughout,  while  in  correspondingly  severe  cases  of  chorea, 
the  patient  deviates  in  all  directions  from  his  intended  course.  Thus,  a 
patient  suffering  from  multiple  sclerosis  will  be  able  to  carry  a  spoon  or 
glass  to  his  mouth  (though  some  of  the  contents  will  be  spilled),  but  in  a 
severe  case  of  chorea,  the  individual  will  strike  the  object  against  his  ear 
or  nose;  as  soon  as  the  spoon  is  about  to  enter  his  mouth,  a  sudden  jerk 
of  the  arm  will  draw  it  forcibly  away.  The  difference  between  the  two 
classes  of  movements  appears  to  me  to  be  best  formulated  by  the  state- 
ment that,  in  chorea,  volition  is  disordered  at  the  time  of  its  development 
in  the  cerebral  cortex  (in  which  I  presume  the  lesion  is  situated),  while  in 
cerebro-spinal  sclerosis,  the  nerve-force  becomes  interfered  with,  as  Char- 
cot expresses  it,  in  its  passage  through  the  affected  portions  of  the  spinal 
cord. 

Only  the  grossest  carelessness  could  give  rise  to  the  mistake  of  re- 
garding the  movements  of  paralysis  agitans  as  choreiform  in  their  na- 
ture. The  former  consist  of  tremor  of  a  limb,  as  a  whole,  the  excursions 
of  the  muscles  being  very  short  and  following  one  another  with  great 
regularity.  Until  the  disease  has  lasted  for  a  very  long  time,  the  move- 
ments can  always  be  quieted  by  a  strong  effort  of  the  will,  thus  differing 
at  the  same  time  from  the  twitchings  of  chorea  and  of  multiple  cerebro- 
spinal sclerosis,  for  which  this  affection  is  also  sometimes  mistaken.  The 
clinical  history  of  paralysis  agitans  and  chorea  is  entirely  different.  Tiie 
former  is  a  disease  of  old  age  (exceptionally  it  occurs  in  middle  life);  it  is 
almost  impossible  to  check  the  disease,  the  movements  rarely  involve  the 
head  (the  movements  of  the  head  are  communicated  from  the  trunk), 
and  the  affected  muscles  usually  present  a  certain  amount  of  rigidi- 
ty— phenomena  which  are  all  entirely  distinct  from  those  observed  in 
chorea. 

The  prognosis  of  chorea,  as  regards  recovery  from  any  single  attack, 
is  ordinarily  good.  As  a  rule,  the  disease,  after  it  has  reached  its  culmin- 
ation, begins  slowly  to  decline,  and  most  cases  have  run  their  course  in  a 
period  varying  from  two  to  four  months.  But  a  considerable  percentage 
of  the  cases  suffer  from  relapses,  and  we  not  infrequently  find,  upon  in- 
quiring into  this  point,  that  the  patient  has  had  an  attack  every  spring 
for  several  years  in  succession,  or  perhaps,  in  alternate  years. 

Sometimes  the  patients  have  two  attacks  in  one  year,  each  lasting 
several  months.  In  these  cases,  as  well  as  in  all  others  in  which  the  dis- 
ease has  lasted  over  six  months,  there  is  danger  that  the  chorea  may  con- 
tinue for  years,  and  even  until  the  end  of  life.  I  have  at  present  a  case 
of  this  kind  under  observation,  in  which  the  choreic  movements  have  con- 
tinued with  undiminished  severity  for  nearly  a  year,  and  in  which  the 
mental  faculties  are  gradually  failing,  so  that  I  apprehend  the  develop- 
ment of  complete  dementia. 

The  prognosis,  as  regards  a  fatal  termination,  is  very  good,  and  not  a 
single  case  of  death  (with  the  exception  of  the  patient  mentioned  on  page 
27,  in  whom  cerebral  sclerosis  was  found  after  death)  has  come  under 
my  notice.  Cases  are  reported,  however,  in  which  exhaustion  and  death 
supervened  on  account  of  the  extreme  violence  of  the  muscular  twitch- 
ings, the  loss  of  sleep  caused  thereby,  the  lack  of  nutrition,  and  some- 
times exhaustion  from  mania.  Such  instances  are,  however,  quite  infre- 
quent, especially  in  this  country.     As  a  rule,  death  is  due  to  the  pres- 


CHOREA.  37 

ence  of  some  intercurrent  afEection,  such  as  cerebral  hemorrhage,  endo- 
carditis, etc. 

The  psychical  complications  of  chorea  present  a  very  favorable  proo-no- 
sis  as  regards  recovery  from  the  mental  affection,  though  we  must  admit 
that  not  an  inconsiderable  proportion  of  the  fatal  cases  have  been  attend- 
ed with  mania.  As  a  rule,  however,  the  patient  entirely  recovers  from 
the  maniacal  disorder,  and  the  improvement  keeps  pace  with  the  diminu- 
tion in  the  choreic  movements,  although  the  mental  disturbance  may 
sometimes  last  several  months  after  the  former  have  disappeared. 


CHAPTER  YI. 

TREATMENT. 

The  first  step  in  the  treatment  of  chorea  is  to  take  the  children  (the 
disease,  as  we  have  seen,  generally  occurs  in  childhood)  away  from  school. 
This  is  beneficial  in  several  ways.  In  the  first  place,  the  memory  is  usu- 
ally impaired  to  a  greater  or  less  extent  in  this  affection,  and  the  little 
patients  are  not  so  bright  and  intelligent  as  in  their  normal  condition. 
The  consequence  is  that  they  must  make  unusual  efforts  to  retain  their 
standing  in  the  class,  and  this  strain,  reacting  upon  an  already  irritable 
brain,  serves  to  aggravate  the  existing  functional  disorder.  Furthermore, 
the  patient's  classmates,  with  the  well-known  inconsiderateness  of  child- 
hood, are  apt  to  deride  and  jeer  the  little  sufferer  on  account  of  the  gro- 
tesque character  of  the  muscular  movements  to  which  he  is  subject,  and 
the  shame  and  anger  which  are  produced  in  this  manner  will  give  rise  to 
the  same  bad  effects  as  those  due  to  mental  overwork. 

Shall  the  patient  be  allowed  to  run  at  will  in  the  open  air  ?  We  are 
aware  that  this  is  the  usual  advice  given  by  the  physician,  but  we  are  not 
by  any  means  convinced  of  its  utility.  Children  are  apt  to  engage  in 
sports  with  all  the  earnestness  of  a  serious  pursuit,  and  usually  become 
thoroughly  tired  out  in  consequence.  This  is  especially  true  with  regard 
to  choreic  children,  whose  muscular  energy  always  becomes  diminished  dur- 
ing the  course  of  the  disease.  It  is  a  well-known  fact,  however,  that  rest 
tends  to  diminish  the  violence  of  choreic  twitchings,  and  for  this  reason, 
although  I  favor  out-of-door  life  for  the  patient,  I  discountenance  any 
rough  sports,  and  prefer  that  he  should  take  short  walks,  carriage-rides, 
etc. 

For  a  similar  reason,  also,  the  patient  should  be  allowed  to  indulge  in 
sufficient  sleep.  Although  the  choreic  movements  usually  begin  as  soon 
as  the  patients  wake,  or  within  a  few  minutes  afterward,  they  are  not  so 
severe  as  they  are  after  the  lapse  of  an  hour  or  two.  Sleep  is  frequently 
disturbed  in  this  affection,  and  as  this  is  sometimes  due  to  the  fact  that 
the  patients  are  worn  out  from  the  constant  muscular  movements,  it  is 
advisable  to  give  the  patients  a  small  quantity  of  ale  or  porter  before  re- 
tiring. When  this  simple  measure  proves  unsuccessful  in  procuring  a 
sound  sleep,  we  are  warranted  in  giving  from  five  to  ten  grain  doses  of 
hydrate  of  chloral  at  night.  We  will  often  find  that  after  several  nights' 
good  rest  has  been  secured  in  this  manner,  the  twitchings  rapidly  dimin- 
ish in  severity.  It  is  not  advisable,  however,  to  continue  the  use  of 
chloral  for  any  length  of  time,  for  we  find  that  in  children  especially  it  is 
apt  to  give  rise  to  bad  after-effects,  and  is  a  very  potent  factor  in  pro- 
ducing and  maintaining  an  aiiEemic  condition. 

Some  of  the  recommendations  presented  by  Dr.  Sturges  with  regard  to 
the  treatment  of  chorea  are  so  excellent  that  we  shall  make  a  short  ab- 
stract from  one  of  his  lectures. 

"  Chorea  is  aggravated  by  emotion  and  close  inspection;  it  ameliorates 


CHOREA.  39 

with  mental  and  bodily  repose  and  preoccupation;  it  ceases  altogether 
in  sleep  and  during  intervals  of  musing.  Any  method  of  treatment 
which  places  the  child  under  obvious  surveillance,  and  thus  makes  it  at- 
tentive to  itself,  must  tend  to  aggravate  the  complaint  and  aid  in  its  de- 
velopment  To  rest  the   overworked   and  tired   limbs,  to 

secure  a  large  measure  of  sleep;  to  make  the  time  pass  evenly,  yet  with- 
out the  weariness  of  monotony;  to  save  the  voluntary  muscles  the  morti- 
fication of  failui-e  by  anticipating  the  child's  wants;  these,  as  I  believe, 
are  the  most  serviceable  duties  which  can  be  rendered  at  the  outset  of 
chorea.  Yet  they  must  be  done  without  ostentation,  and  without  the 
child  perceiving  that  he  is  being  tended  and  watched  and  treated  as  one 
sick." 

The  patients  should  be  allowed  a  free,  generous  diet,  and  no  restriction 
need  be  made  with  regard  to  the  character  of  the  food,  except  under 
special  circumstances.  As  in  all  neuroses,  which  are  evidence  of  a  low 
condition  of  nervous  tone,  it  is  well  to  introduce  as  much  fat  as  possible 
into  the  food,  and  with  this  end  in  view  we  may  administer  milk  and  cod- 
liver  oil.  In  the  majority  of  cases  the  appetite  is  poor  and  usually  capri- 
cious, and  we  may  then  prescribe  some  of  the  simple  bitters  (calumba, 
quassia,  gentian). 

A  considerable  number  of  the  patients  are  anaemic  from  the  beginning, 
while  a  much  larger  number  become  so  in  consequence  of  the  character 
of  the  disease.  In  these  cases,  mild  ferruginous  tonics  are  indicated,  such 
as  dialyzed  iron  or  carbonate  of  iron,  or  the  tincture  of  the  chloride  of 
iron,  which  is  preferable  when  the  digestive  organs  are  in  good  condition. 
It  is  unnecessary,  however,  to  administer  iron  as  a  routine  matter  of 
treatment,  as  is  so  frequently  done,  under  the  impression  that  iron  pos- 
sesses a  certain  specific  influence  in  the  treatment  of  the  disease. 

The  medicinal  treatment  of  chorea  is  extremely  unsatisfactory.  Gray 
and  Tuckwell  found  that  the  average  duration  of  thirty-eight  cases,  which 
were  treated  on  the  expectant  plan,  was  nine  weeks  and  six  days.  The 
average  duration  when  treated  with  arsenic  in  gradually  increasing  doses, 
according  to  Begbie's  plan,  was  ten  to  eleven  weeks.  See  gave  sixty- 
nine  days  as  the  average  duration  of  117  cases  treated  with  various  medi- 
cines, and  it  is  a  curious  coincidence  that  this  agrees  exactly  with  the 
duration  of  Gray's  and  Tuckwell's  cases.  The  majority  of  observers 
agree  that  recovery  within  two  to  three  months  constitutes  a  good  result. 
My  usual  plan  of  treatment  is  to  put  the  patient  on  three  to  five  drop 
doses  of  Fowler's  solution  (three  times  a  day,  immediately  after  meals,  in 
a  little  water),  and  increase  this  amount  by  one  drop  at  a  dose  until  some 
of  the  toxic  effects  become  evident  (nausea,  sometimes  vomiting  or  loose- 
ness of  the  bowels,  slight  oedema  of  the  eyelids,  perhaps  pitting  over  the 
tibice).  The  drug  is  then  discontinued  for  a  few  days  until  these  symp- 
toms have  subsided  (an  alkaline  drink  such  as  Vichy  water  will  accelerate 
their  disappearance),  and  it  is  then  again  administered  in  doses  slightly 
smaller  than  those  which  sufficed  to  produce  the  above-mentioned  toxic 
effects.  If  it  produces  any  good  results,  the  remedy  may  be  continued 
in  this  manner  for  a  period  of  six  or  eight  weeks.  I  have  found  that  al- 
though this  plan  of  treatment  will  not  cut  short  the  disease,  the  move- 
ments will  become  very  much  milder  within  ten  days  or  two  weeks,  but 
that  some  amount  of  motor  disturbance  will  persist  until  the  disease  has 
rvin  its  natural  course  (two  to  three  months). 

When  the  muscular  twitchings  are  of  an  extremely  violent  character, 
interfere  with  sleep,  and  threaten  to  produce  serious  prostration,  I  have 


40  FUlirCTIONAL    NEKYOUS    DISEASES. 

obtained  good  results  from  the  use  of  a  mixture  of  bromide  of  potassium 
and  hydrate  of  chloral.  The  dosage  depends  upon  the  severity  of  the  in- 
dividual case,  but  the  largest  amount  should  be  given  at  night.  Pro- 
longed warm  baths  (fifteen  minutes  to  half  an  hour),  are  also  useful  under 
these  circumstances.  The  movements  are  sometimes  so  violent  that  it 
becomes  necessary  to  tie  the  patient  in  bed  in  order  to  prevent  him  from 
doing  injury  to  himself.  It  is  well  in  all  cases  of  such  severity  to  keep 
the  patient  in  bed  continuously  until  the  excessive  violence  of  the  move- 
ments subside.  The  condition  of  the  integument  should  be  carefully  ex- 
amined from  day  to  day  in  order  to  detect  the  development  of  excori- 
ations, which  are  liable  to  be  produced  from  the  violent  friction  of  the 
parts  against  surrounding  objects. 

During  the  past  year  I  have  made  quite  extensive  use  of  inhalations 
of  nitrite  of  amyl,  beginning  with  two-drop  doses  three  times  a  day  and 
gradually  increasing  to  six  or  seven  drop  doses.  It  has  seemed  to  me  that 
its  effects  may  be  compared  with  those  of  Fowler's  solution,  i.  e.,  it  pro- 
duces considerable  improvement  within  one  or  two  weeks,  but  the  disease 
then  runs  its  usual  course. 

It  is  well  to  bear  in  mind,  in  treating  chorea,  that  the  patients  rarely 
fall  into  our  hands  until  the  disease  has  lasted  for  a  longer  or  shorter 
period,  and  that  part  of  the  effect,  which  we  attribute  to  our  remedies, 
may  be  due  to  Dame  Nature. 

Strychnia  has  been  highly  recommended  by  many  writers.  We  must 
exercise  caution  in  its  administration  to  children,  as  they  not  infrequently 
present  a  peculiar  susceptibility  to  its  influence.  A  child  of  eight  or  nine 
years  should  not  receive  more  than  one  one-hundredth  of  a  grain  at  a 
dose  in  the  beginning,  and  this  quantity  may  then  be  gradually  and 
cautiously  increased.  In  my  hands  the  drug  has  proven  almost  useless 
except  as  a  nerve-tonic. 

Within  the  last  few  years  Bouchut  has  introduced  eserine  as  a  remedy 
in  this  disease,  and  claims  truly  wonderful  results  in  a  very  large  number 
of  cases.  It  was  administered  in  doses  of  about  one-sixtieth  of  a  grain, 
either  by  the  mouth  or  as  a  hypodermic  injection,  and  Bouchut  claims 
that  the  majority  of  cases  recovered  within  two  weeks.  These  remarka- 
ble results  have,  however,  not  been  obtained  by  other  observers,  and  its 
administration  is  sometimes  attended  with  such  disagreeable  effects  (vom- 
iting, prostration,  etc.)  that  I  have  entirely  refrained  from  using  it. 

Curare  has  been  successfully  employed  in  a  few  cases  of  chorea  of  old 
age,  which  is  usually  regarded  as  incurable.  This  is  given  in  doses  of 
one-tenth  of  a  grain  in  the  beginning,  and  of  course  by  means  of  hypo- 
dermic injection,  since  it  is  well  known  that  when  this  drug  is  adminis- 
tered by  the  mouth,  it  is  eliminated  so  rapidly  by  the  kidneys  that  no 
effects  upon  the  nervous  system  are  produced.  If  good  results  are  not 
obtained  within  a  week  after  beginning  its  use,  it  would  be  unwise  to 
continue  its  administration. 

Numerous  other  drugs  have  been  employed  in  the  treatment  of  this 
disease,  but  it  is  unnecessary  to  refer  to  them,  as  none  of  them  have  stood 
the  test  of  experience. 

Ottomar  Rosenbach  has  advised  the  employment  of  the  constant  gal- 
vanic current  and  of  counter-irritation  applied  to  the  tender  spots  which 
are  found  along  the  spinal  column.  I  resorted  to  this  plan  of  treatment 
in  three  cases,  but  without  obtaining  the  slightest  improvement.  Nu- 
merous observers  have  employed  the  constant  current  (to  the  spine)  in 
treating  chorea,  but  the  large  majority  concur  in  the   opinion  that  it  is 


CHOEEA.  41 

either  entirely  useless,  or  that  its  temporary  musculo-sedative  effects  soon 
disappear. 

In  the  severe  cases  which  are  attended  with  maniacal  excitement  and 
extremely  violent  muscular  contortions,  it  is  advisable  to  put  the  patient 
in  a  straight  jacket/  administer  large  doses  of  bromide  of  potassium  and 
chloral,  and  endeavor,  by  every  means  in  our  power,  to  feed  the  patient. 
When  this  cannot  be  done  by  the  mouth  or  through  the  stomach-tube, 
nutritious  enemata  should  be  at  once  resorted  to.  In  administering  hy- 
drate of  chloral  in  such  cases,  we  should  bear  in  mind  that  the  continual 
movements  of  the  body  tend  to  antagonize  the  effects  of  the  druo-^  and 
that  large  doses  (ten  to  thirty  grains,  or  even  more)  sliould  be  given. 
"When  the  choreic  twitchings  can  be  controlled  in  no  other  manner,  we 
may  be  compelled  to  resort  to  inhalations  of  chloroform. 

'  This  is  advisable,  not  on  account  of  the  mania,  but  merely  to  moderate  the  exces- 
sive muscular  twitchings,  the  production  of  which  is  a  source  of  fresh  contortions. 


EPILEPSY. 


CHAPTER  I. 

CLINICAL  HISTORY. 


This  dread  disease  has  been  known  since  the  earliest  periods  in  the 
history  of  medicine,  and  has  always  attracted  the  attention  alike  of  the 
profession  and  of  the  laity.  The  peculiar  character  of  the  symptoms,  and 
the  usually  incurable  nature  of  the  malady,  caused  it  to  be  looked  upon 
as  an  evidence  of  demoniac  possession.  The  terms  applied  to  it  by  the 
lower  classes,  in  some  countries,  indicate  that  this  view  obtains  even  at 
the  present.  The  conception  which  was  formed  of  the  disease  remained 
unchanged  for  centuries,  and  it  is  only  within  comparatively  recent  times 
that  our  views  concerning  the  scope  and  boundaries  of  this  affection  have 
undergone  a  radical  change  and  amplification.  It  was  formerly  regarded 
as  a  paroxysmal  disease,  in  which  the  paroxysms  consisted  essentially  of 
unconsciousness  and  general  convulsive  movements,  but,  at  the  present  time 
this  combination  of  symptoms  is  only  looked  upon  as  characteristic  of  one 
form  of  epilepsy,  viz.,  the  grand  mal.  In  addition  to  this  variety  there 
are  cases  in  which  the  loss  of  consciousness  is  the  only  symptom,  the 
convulsive  movements  being  entirely  absent.  These  two  varieties  are 
not,  however,  sharply  separated  from  one  another,  and  there  are  forms 
which  are  intermediate  between  the  two,  i.  e.,  there  are  cases  in  which 
the  unconsciousness  is  combined  with  partial  convulsions.  There  is  an- 
other variety  in  which  the  attacks  are  characterized  by  peculiar  groups 
of  actions  performed  while  the  patient  is  in  an  unconscious  or  partly  un- 
conscious condition.  Finally,  a  new  group  has  been  placed  under  this 
head  by  Griesinger,  who  applied  the  term  "  epileptoid  states  "  to  the 
manifestations  in  question. 

Grand  Mal. 

We  shall  first  enter  upon  the  consideration  of  epilepsia  gravior, 
or  the  grcuid  inal.  The  history  of  the  affection  embraces  two  parts, 
viz.,  the  paroxysm  itself  and  the  interparoxysmal  period.  The  attack 
frequently  begins  without  any  warning.  The  patient,  while  engaged 
in  his  ordinary  occupations,  suddenly  loses  consciousness,  his  face  grows 
pale,  and  at  times  he  utters  a  peculiar  inarticulate  cry.  He  then  falls  as 
if  struck  by  a  heavy  blow,  and  the  convulsive  phenomena  immediately  be- 
come apparent.     The  stage  of  tonic  convulsions  now  begins.     The  spasms 


44  FUIJ^CTIONAL    NERVOUS   DISEASES. 

appear  first  in  the  muscles  of  the  face  or  the  small  muscles  of  the  hand, 
and  then  rapidly  spread  throughout  the  entire  body.  Slight  twitchings 
are  observed  in  the  muscles  inserted  into  the  angles  of  the  mouth;  the 
eyes  become  fixed  and  are  usually  drawn  to  one  side;  the  muscles  of  the 
neck  contract,  and  frequently  draw  it  to  the  side  toward  which  the  eyes 
are  turned;  the  muscles  of  the  hand  contract,  and  draw  the  thumb  firmly 
into  the  palm,  and  the  fingers  are  clenched.  At  the  same  time  the  mus- 
cles of  respiration,  including  the  diaphragm,  are  similarly  affected  and  im- 
pede the  act  of  breathing;  this  is  immediately  followed  by  powerful  tonic 
contractions  throughout  all  the  muscles  of  the  body.  During  the  entire 
stage,  which  only  lasts  from  a  few  seconds  to  a  couple  of  minutes,  the 
body  does  not  move  from  the  position  in  which  it  has  fallen.  These  con- 
tractions may  be  so  powerful  that  the  head  is  drawn  forcibly  backward, 
and  the  entire  body  is  in  a  condition  of  slight  opisthotonos,  or,  if  the  con- 
tractions are  stronger  on  one  side,  as  they  frequently  are,  in  a  condition 
of  emprosthotonos.  The  tonic  sj^asm  of  the  muscles  then  begins  to  relax, 
and  clonic  convulsions  make  their  appearance,  at  first  mild  and  local- 
ized and  then  growing  more  diffuse  and  violent,  until,  in  a  very  short 
time,  the  whole  body  is  in  a  continual  state  of  violent  muscular  contrac- 
tion and  relaxation.  The  face,  which  had  begun  to  grow  dark  during  the 
latter  part  of  the  tonic  stage,  now  becomes  dusky  and  turgid,  the  eyes 
stare,  and  the  features  are  disfigured  by  terrible  grimaces  and  contortions. 
During  this  period,  the  tongue,  which  has  been  protruded  by  the  violence 
of  the  muscular  action,  is  frequently  caught  between  the  rapidly  closing 
jaws.  After  a  variable  period  (usually  from  two  to  five  minutes)  this 
condition  subsides.  The  clonic  contractions  sometimes  cease  quite  sud- 
denly, but  usually  they  grow  milder  gradually,  the  dusky  hue  of  the  face 
and  body  begins  to  disappear,  and  the  patient  then  lays  perfectly  quiet. 
In  some  cases,  he  immediately  rouses  from  his  comatose  condition,  opens 
his  eyes,  and  looks  around  him  with  a  stupid,  frightened  air,  mutters, 
perhaps,  some  inarticulate  words,  and  then  rapidly  lapses  into  his  prev- 
ious condition.  Generally,  however,  he  falls  into  a  deep,  lethargic  sleep, 
from  which  he  may  be  roused  into  consciousness,  and  wakes  up  after  a 
period  varying  from  a  few  minutes  to  several  hours;  the  epileptic  coma 
has  even  been  known  to  continue  forty-eight  hours.  The  patient  usu- 
ally wakes  feeling  dull  and  heavy,  complains  of  headache,  and  has  a  tired 
aching  feeling  in  the  muscles,  as  if  he  had  been  engaged  in  some  very 
heavy  work. 

The  attacks  do  not  always  begin  as  suddenly  as  we  have  described, 
but  in  some  cases  prodromata  are  experienced,  so  that  the  patients  can 
always  foretell  the  occurrence  of  a  convulsion.  Opinions  vary  with  re- 
gard to  the  frequency  of  these  symptoms.  Some  authorities,  including 
Romberg  and  Sieveking,  state  that  they  have  met  them  in  one-half  of  all 
their  cases,  others  have  observed  them  with  much  less  frequency. 

The  character  of  these  prodromic  symptoms  is  manifold;  they  are  usu- 
ally classified  into  the  remote  and  immediate.  The  former  may  last  for 
one,  two,  or  even  three  days,  and  are  often  manifested  by  a  change  in  the 
disposition  of  the  patient.  If  he  has  previously  been  in  his  usual  condi- 
tion of  cheerfulness,  he  now  becomes  gloomy  and  irritable,  and  is  liable 
to  causeless  attacks  of  anger;  or,  perhaps,  a  sullen  state  gives  way  to  a 
more  cheerful  demeanor.  If  those  surrounding  the  patient  are  attentive 
and  observant,  they  are  generally  able  to  tell,  from  this  change  of  dispo- 
sition, that  a  convulsion  is  impending.  Reynolds  has  also  noticed  a  pecu- 
liar remote  prodroma,  consisting  of  a  duskiness  of  the  skin,  especially 


EPILEPSY.  45 

affecting  the  face  and  neck,  this  symptom  being  observed  from  four  to 
twelve  hours  before  the  onset  of  the  attack. 

In  one  case  under  my  observation,  the  patient,  for  twenty-four  to  tliirty- 
six  hours  before  the  fit,  has  prodromata  wliich  consist  of  palpitation  of 
the  heart,  and  a  feeling  of  heat  arising  from  the  prnecordium,  together 
with  pain  and  a  feeling  of  distention  in  the  abdomen;  she,  also,  has  a 
flushed  face  and  headache  during  this  period. 

In  another  case,  the  patient  feels  dull,  and  complains  of  pain  in  the 
frontal  reo-ion  for  about  a  day  before  the  fit;  during  this  time  she  also 
has  a  watery  diarrhoea  (ten  to  twelve  passages)  although  the  bowels  are 
perfectly  regular  at  other  times.  I  also  have  under  my  care  a  patient 
in  whom  these  abdominal  prodromata  are  very  well  marked  (I  may  men- 
tion here  that  these  three  patients  are  females).  The  patient  in  question 
is  fortv-eight  j^ears  old,  and  has  had  epileptic  attacks  during  the  last  ten 
vears.  For  twentj'-four  hours  before  the  attack  begins,  she  suffers  from  un- 
controllable vomiting  and  diarrhoea,  so  that  she  is  compelled  to  keep  to  her 
bed.  At  times  this  is  accompanied  by  intense  pain  in  either  forehead,  or 
by  exquisite  hvpertesthesia  in  localized  spots  in  various  parts  of  the  limbs. 
Immediately  before  the  convulsion  begins,  the  patient  has  a  sensation  as 
if  a  large  ball  were  situated  in  the  anus,  this  appears  to  move  up  the 
rectum,  and  then  passes  to  the  lumbar  region  of  the  spine,  along  which  it 
mounts;  she  then  loses  consciousness  and  has  a  severe  convulsion. 

An  extremely  rare  prodromal  symptom  was  observed  by  Kuethe.' 
He  found  that  the  individual  in  question  manifested  agraphia  prior  to  one 
of  his  attacks.  The  patient,  who  was  a  book-keeper,  was  attacked  with 
a  convulsion  while  engaged  in  writing  in  his  account  books.  An  exami- 
nation of  these  books  showed  that  before  the  attack  began,  the  patient 
made  wrong  entries,  repeated  certain  syllables  several  times  in  succession, 
and  introduced  words  which  had  no  bearing  on  the  accounts. 

The  immediate  prodromata  are  usually  known  under  the  term  aura, 
and  are  much  more  variable  in  their  appearance.  They  may  be  classified 
as  psychical,  motor,  sensory,  and  vaso-motor. 

At  times  the  patients  feel  giddy  immediately  before  the  attack,  and 
this  feeling  sometimes  lasts  sufficiently  long  to  allow  them  to  secure 
a  safe  position  before  the  convulsion  occurs.  At  other  times  they  expe- 
rience a  peculiar  feeling  in  the  head,  which  only  lasts  for  a  few  seconds, 
and  which  very  intelligent  patients  have  told  nie  is  perfectly  indescrib- 
able. Or,  the  patient  may  be  in  a  peculiar  state  of  excitement,  and 
evince  great  loquacity  for  a  few  seconds  or  minutes  before  the  fit. 

The  sensory  aura  are  more  variable  than  the  psychical  ones.  Some- 
times the  convulsion  is  preceded  by  peculiar  hallucinations.  Watson  re- 
lates that  Dr.  Gregory,  of  Edinburgh,  was  assured  by  a  patient  of  un- 
doubted veracity,  "  that  always  when  he  had  a  fit  of  epilepsy  approaching 
he  fancied  that  he  saw  a  little  old  woman  in  a  red  cloak,  who  came  up  to 
him  and  struck  him  a  blow  on  the  head,  and  then  he  immediately  lost  all 
recollection  and  fell  down." 

The  visual  prodromata  may  also  merely  consist  of  sensations  of  light, 
in  which  the  red  color  appears  to  predominate.  An  affection  of  the 
acoustic,  olfactory  and  gustatory  nerves  is  also  sometimes  met  with. 
Thus,  the  patient  may  hear  a  buzzing  or  roaring  noise  in  the  ears,  ringing 
of  bells,  may  smell  a  peculiar  stench,  or  have  a  curious  taste  in  the  mouth. 
In  one  case,  a  patient  of  mine,  before  having  the  fits  thought  he  heard  a 

'  Arch.  f.  Psych.  1879,  pp.  257-260. 


46  rCJNCTIONAL    NERVOUS    DISEASES. 

buzzing-  noise  above  him,  which  came  down,  entered   his  head,  and  then 
went  to  his  stomach,  after  which  he  lost  consciousness. 

The  nerves  of  general  sensibility  are  affected  as  well  as  those  of  special 
sense.  In  fact,  the  term  aura,  which  refers  to  the  sensation  of  a  breath, 
strictly  applies  only  to  sensory  prodromata.  The  latter  may  consist  of 
painful  sensations,  starting-  from  some  part  of  the  trunk  or  limbs  and  ris-' 
ing  rapidly  to  the  head,  or  of  a  sensation  in  the  head  as  if  something  had 
cracked  there,  etc.  Instead  of  pain  there  may  be  a  sensation  of  numb- 
ness, or  even  true  ansesthesia.  Nothnagel  relates  that  in  some  of  his  pa- 
tients, in  whom  this  phenomenon  lasted  ten  minutes  or  longer,  he  was  able 
to  detect  a  palpable  diminution  of  sensitiveness  to  the  prick  of  a  pin  or 
to  changes  of  temperature.  A  very  frequent  sensory  aura  consists  of  a 
feeling  of  pain  in  the  epigastrium  or  lower  down  in  the  abdomen,  which 
rapidly  rises  to  the  throat;  in  other  cases,  the  patients  describe  the  sen- 
sation as  of  a  jumping  or  jerking  character,  although  no  movements  can 
be  observed.  As  soon  as  the  sensation  reaches  the  throat  or  head,  uncon- 
sciousness supervenes.  I  have  already  referred  to  the  case  in  which  the 
patient  felt  as  if  a  large  ball  started  from  the  anus  and  ran  up  the  rec- 
tum; it  then  appeared  to  pass  up  to  the  back,  after  which  the  fit  imme- 
diately developed. 

The  motor  aura  consist  either  of  muscular  contractions  or  paralysis, 
which  usually  affect  one  limb  or  even  the  whole  side  of  the  body.  The 
paralytic  aura  is  extremely  rare,  and  has  never  come  under  my  notice; 
some  authorities  even  doubt  its  existence.  The  motor  aura  is  readily  under- 
stood from  a  few  illustrative  cases.  In  one  typical  example  the  patient, 
a  young  man,  while  strapping  his  valise  very  tightly,  noticed  that  his  right 
hand  became  violently  extended  and  was  then  rapidly  flexed;  he  turned 
to  walk  to  his  father,  who  was  standing  at  some  distance  from  him,  and 
while  doing  so,  the  clonic  contractions  spread  to  the  forearm  and  then  to 
the  arm;  he  then  lost  consciousness,  and  the  convulsion  developed.  In 
another  case,  a  man,  who  had  received  an  injury  to  the  lower  and 
outer  part  of  the  left  leg  several  months  previously,  observed  some  twitch- 
ings  in  this  part  which  then  spread  to  the  thigh,  the  left  side,  and  finally 
the  left  arm,  after  which  he  immediately  became  unconscious.  At  times, 
also,  the  muscular  twitchings  may  begin  in  the  face.  Sometimes  the  pa- 
tient performs  rotatory  movements,  or  even  walks  or  runs  a  few  paces, 
before  the  convulsion  develops. 

A  vaso-motor  aura  is  also  not  infrequent;  it  may  consist  of  flashes  of 
heat  or  cold,  or  patches  of  pallor  or  redness  appear  in  different  parts  of 
the  skin.  The  aura  may  be  limited  to  one  limb  or  to  the  side  of  the  face; 
the  part  affected  becomes  red,  hot,  and  perspiring,  or  the  reverse  phe- 
nomena are  noticed.  This  condition  begins  at  the  extremity  of  the  limb 
and  runs  upward  to  the  neck  or  head. 

It  is  sometimes  evident  that  epileptic  children  who  are  too  young  to 
describe  their  sensations,  have  an  aura  preceding  their  attacks.  In  sev- 
eral cases  the  mothers  of  such  children  have  informed  me  that  whenever 
the  patient  was  about  to  have  a  fit,  he  would  run  to  them,  with  a  pecu- 
liar expression  of  dread,  as  if  for  protection.  As  far  as  I  am  able  to 
learn,  however,  the  aura  in  such  young  children  is  probably  of  a  psy- 
chical nature,  as  I  have  been  unable  to  obtain  any  history  of  objective 
changes  in  the  little  patients  prior  to  the  attack. 

It  not  infrequently  happens — in  fact,  we  may  observe  in  almost  all 
chronic  cases  in  which  the  fits  occur  with  great  frequency — that  the  aura 
sometimes  makes  its  appeara^nce,  but  is   not  followed  by  a  convulsion. 


EPILEPSY.  47 

At  times  this  is  merely  an  effect  of  the  natural  course  of  the  disease;  but, 
since  the  use  of  nitrite  of  amyl  has  come  into  vogue  in  the  treatment  of 
epilepsy,  I  have  noticed  more  frequently  than  formerly  that  the  inhala- 
tion of  a  few  drops  during  the  development  of  the  aura  has  been  instru- 
mental in  staving  off  the  fit.  I  have  also  often  observed  that  one  of  the 
first  signs  of  improvement,  under  the  use  of  the  bromides,  is  the  fact  that 
the  aura  merely  appears  instead  of  the  fully  developed  convulsion. 

As  we  shall  see  at  a  later  period,  the  aura  sometimes  furnishes  valu- 
able indications  with  regard  to  the  origin  of  the  epilepsy,  and  may  thus 
prove  very  important  with  regard  to  treatment. 

We  shall  now  examine  the  phenomena  directly  connected  with  the 
convulsion  more  in  detail. 

The  so-called  epileptic  cry  is  not  observed  in  more  than  half  the 
cases.  In  some  instances  it  is  so  low  that  it  cannot  be  heard  at  a  dis- 
tance of  more  than  a  few  feet  (this  has  been  the  rule  in  my  experience), 
but  at  other  times  it  is  extremely  loud.  While  I  was  interne  in  the 
Hospital  for  Epileptics  and  Paralytics,  I  was  once  awakened  by  a  pierc- 
ing shriek  which  appeared  to  emanate  from  the  adjacent  ward.  Upon 
hurriedly  entering  the  ward  I  found  one  of  the  patients  in  a  convulsion; 
upon  recovering,  she  told  me  that  she  had  been  unconscious  of  the  utter- 
ance of  this  cry,  although  it  had  been  loud  enough  to  rouse  me  from  a 
sound  sleep  at  a  distance  of  more  than  fifty  feet  from  the  patient's  bed. 
In  all  the  cases  in  which  I  was  able  to  obtain  any  information  upon  the 
point,  the  patient  was  already  unconscious  at  the  time  the  cry  was  emit- 
ted. Dr„  Reynolds,'  however,  observed  one  case  which  proves  that  it 
may  be  uttered  while  consciousness  is  still  present.  "The  individual  re- 
ferred to  was  aware  that  he  was  making  the  noise,  but  he  could  not  ar- 
rest it;  he  heard  remarks  made  in  another  room,  and  made  signals  to  his 
child  to  leave  the  room;  but  then  lost  all  perception  and  volition." 

It  is  probable  that  the  cry  is  merely  due  to  the  vigorous  tonic  con- 
traction of  the  muscles  of  expiration.  The  theory  that  it  is  the  result  of 
a  sensation  of  terror  or  surprise  has  not  been  substantiated. 

It  appears  from  the  united  testimony  of  all  observers  that  the  face  is 
usually  pale  at  the  onset  of  the  attack,  but  there  are  numerous  excep- 
tions to  this  rule.  Not  infrequently  the  color  of  the  face  is  unchanged 
until  toward  the  close  of  the  tonic  stage,  and,  in  a  few  exceptional  cases, 
I  have  been  informed  by  the  friends  of  the  patient  that  the  face  became 
of  a  bright  red  color  at  the  beginning  of  the  convulsion.  If  the  clonic 
convulsions  are  at  all  marked,  the  face  becomes  dusky  and  puffed,  and 
this  condition  is  intensified  the  more  vigorous  the  contractions  of  the 
muscles  of  the  neck  (trachelismus  of  Marshall  Hall)  have  been.  The  pu- 
pils, as  I  have  frequently  had  the  opportunity  to  notice,  dilate  from  the 
beginning  and  remain  in  this  condition  until  the  subsidence  of  the  clonic 
stage.  Some  authors  have  observed  that  during  this  latter  period  they 
may  alternately  contract  and  expand,  but  they  attain  their  normal  size 
when  the  patient  recovers  consciousness.  It  has  been  said,  as  the  result 
of  ophthalmoscopic  examination  during  the  first  period  of  the  fit,  that  the 
fundus  of  the  eye  is  in  an  anasmic  condition.  But,  apart  from  the  scarcity 
of  these  observations,  the  time  for  examination  is  so  short,  and  the  diffi- 
culties connected  with  its  performance  under  such  circumstances  are  so 
great  that  we  are  not  disposed  to  lay  much  stress  upon  these  results. 

'  Epilepsy ;  Its  Symptoms,  Treatment,  and  Relation  to  Other  Chronic  Convulsive 
Diseases. 


48  ruNCTioisrAL  neevoijs  diseases. 

The  examination  of  the  pulse  during  an  epileptic  convulsion  is  at- 
tended with  great  difficulties  on  account  of  the  incessant  movements  of 
the  muscles  of  the  limbs.  In  some  cases,  indeed,  the  examination  is  ren- 
dered impossible. 

At  times  we  are  unable  to  detect  any  appreciable  change  in  the  fre- 
quency or  fulness  of  the  pulse  during  the  entire  paroxysm.  It  appears, 
however,  from  the  observation  of  numerous  authors,  that  the  pulse  is 
usually  small  during  the  tonic  stage,  and  in  some  instances  it  has  been 
found  absent  at  the  wrist,  although  the  carotids  were  beating  visibly  and 
forcibly.  When  the  pulse  can  be  felt  during  the  clonic  stage,  it  is  rapid 
and  full,  and  the  heart  at  this  time  beats  tumultuously. 

Magnan  '  found,  as  the  result  of  his  investigations  with  the  sphygmo- 
graph,  that  during  the  tonic  period  the  arterial  tension  is  increased,  and 
the  semitetanized  heart  beats  with  greater  frequency.  In  the  clonic 
period,  on  the  contrary,  the  cardiac  pulsations  are  accomplished  with  ex- 
treme slowness,  and,  at  a  later  period,  assume  their  normal  rhythm,  or 
may  even  become  slightly  accelerated.  Voisin  *  states  that  the  ascending 
branch  of  the  sphygmographic  tracing  is  higher  than  normal,  and  that 
marked  dicrotism  is  manifested  for  some  time  after  the  cessation  of  the 
fit.  He  regards  these  appearances  as  sufficient  to  diagnose  a  case  of 
simulation  from  a  real  attack  of  epilepsy.  Magnan,  however,  believes 
that  the  sphygmograph  will  render  no  assistance  in  this  respect. 

These  conflicting  statements  with  regard  to  the  condition  of  the  pulse 
during  and  immediately  after  an  epileptic  paroxysm,  show  that  no  defi- 
nite symptoms  are  manifested  in  this  respect. 

Let  us  now  enter  a  little  more  closely  into  the  character  of  the  mus- 
cular contractions  themselves.  The  first,  or  tonic  stage,  varies  very  much, 
both  as  regards  extent  and  intensity.  At  times  this  period  may  be  en- 
tirely absent,  and  the  scene  may  be  opened  with  clonic  convulsions,  which 
persist  to  the  end  of  the  seizure,  or,  on  the  contrary,  this  first  stage  may 
entirely  predominate  the  scene,  the  clonic  convulsions  being  either  en- 
tirely wanting,  or  of  a  very  mild  character.  The  contractions  may  be 
present  in  every  muscle  of  the  body.  Nothnagel  even  mentions  a  case  in 
which  the  epileptic  cry  was  followed  b}''  an  active,  whistling  inspiration, 
such  as  is  only  seen  in  well-marked  spasm  of  the  glottis.  It  is  some- 
times noticed  in  the  beo-inninor  of  this  stag'e  that  the  face  and  neck  are 
drawn  to  one  side  by  tonic  contractions  of  the  muscles  before  the  patient 
falls,  after  which  the  general  convulsions  make  their  appearance. 

The  clonic  convulsions  also  vary  greatly  in  their  intensity.  Sometimes 
they  are  so  severe  as  to  cause  great  bodily  injury.  Thus  the  tongue  may 
be  severely  bitten,  or  even  entirely  divided,  teeth  may  be  broken,  the 
lower  maxillary  bone  or  clavicle  fractured,  and  various  muscles  may  be 
ruptured  from  the  intensity  of  their  contraction.  During  this  stage,  the 
urine,  semen,  and  ffeces  are  often  passed  involuntarily.  As  we  shall  see 
in  the  chapter  on  diagnosis,  the  latter  phenomena  are  sometimes  very 
important  in  putting  us  on  the  track  of  nocturnal  epilepsy. 

Both  stages  of  the  convulsion,  when  severe,  lead  to  great  stasis  in  the 
vessels,  and  this  may  be  followed  by  ruptures  in  the  minute  blood-vessels, 
giving  rise  to  the  development  of  a  petechial  eruption  in  the  integument. 
This  is  usually  visible  around  the  outer  angles  of  the  eye,  but,  in  severe 
cases,  the  entire    face  is  involved  and  presents  a  speckled    appearance. 

'  Gaz.  mc-d.  de  Paris,  1877. 

'  Anuales  d'hygiene  publique,  April,  18G8. 


EPILEPSY.  49 

This  may  likewise  be  an  important  diagnostic  sign  in  doubtful  cases.  It 
is  a  s^^nptom  which  cannot  be  simulated,  but  unfortunately  its  absence 
does  not  exclude  the  diagnosis  of  epilepsy. 

Unconsciousness  is  usually  complete  during  both  stages  of  the  fit. 
The  cornea  may  be  touched  without  any  response;  the  patients  may  fall 
into  the  fire  and  be  horribly  burned  without  their  knowledge,  and  they  have 
been  known  to  drown  in  half  an  inch  of  water  in  cases  in  which  they  have 
fallen  face  foremost  into  a  cistern  or  bath-tub.  The  history  of  a  case 
which  was  very  interesting  in  this  respect  was  told  me  by  my  friend.  Dr. 
Janeway.  A  man  had  been  found  dead  and  was  brought  to  the  dead-house 
without  a  previous  history.  Upon  making  the  autopsy,  Dr.  .Janeway 
found,  as  the  sole  cause  of  death,  the  presence  of  some  dung  in  the  larynx, 
which  had  given  rise  to  asphyxia.  This  led  him  to  suspect  that  the  man 
had  been  an  epileptic,  and  had  probably  fallen  face  foremost  upon  a 
dung-heap,  during  a  convulsion.  An  investigation  into  the  circumstances 
of  the  man's  death  proved  the  correctness  of  this  surmise. 

But  consciousness  may  be  entirely  unaffected  even  during  undoubted 
attacks  of  grand  mal.  In  one  case  under  my  observation,  the  patient,  a 
very  intelligent  man,  assured  me  that  during  the  first  five  years  of  his 
disease  the  seizures  were  accompanied  with  loss  of  consciousness,  but 
that  for  a  year  afterward,  although  the  body  was  strongly  convulsed,  he 
retained  his  consciousness  throughout  the  attacks.  I  should,  however, 
mention  with  regard  to  this  patient  that  the  epilepsy  was  undoubtedly 
due  to  a  syphilitic  cerebral  gumma. 

According  to  Romberg,  reflex  action  may  be  retained  throughout  the 
attack,  although  consciousness  is  lost  ;  this  author  states  that  pouring  cold 
water  on  the  body  gives  rise  to  reflex  muscular  contractions. 

I  desire  to  call  attention  to  a  peculiar  anomaly  with  regard  to  the  oc- 
currence of  coma,  which  is  exemplified  in  the  following  case,  whose  paral- 
lel I  have  been  unable  to  find  in  the  literature  of  epilepsy. 

Case  I. — J.  B.,  set.  32  years,  family  history  excellent,  patient  is 
married,  and  has  seven  healthy  children;  excessive  sexual  indulgence. 
He  was  perfectly  healthy  until  about  four  years  ago,  at  which  time  he 
was  compelled,  in  the  course  of  his  work,  to  enter  an  ice-house  for  an 
hour  and  a  half  every  afternoon,  the  patient  always  being  in  a  state  of 
perspiration  at  the  time  of  entrance.  About  this  time,  while  he  was 
going  to  work  one  morning,  he  suddenly  felt  dizzy  and  weak,  and  a 
small  amount  of  water-brash  regurgitated  from  his  stomach  and  ran  out 
of  his  mouth.  Since  then  he  has  had  spells  of  this  nature  every  day,  or 
even  two  or  three  times  a  day.  At  times  he  had  an  aura  immediately 
preceding  the  attack,  consisting  of  a  feeling  of  powerlessness  in  the  left 
arm.  At  other  times,  he  would  experience  a  feeling  of  pruritus  in  the 
left  eye,  would  then  put  his  hand  up  to  rub  it  and  in  a  few  seconds  con- 
sciousness became  partly  clouded.  In  several  of  these  attacks,  the  patient 
states  that  he  thinks  he  lost  consciousness  entirely  for  a  few  seconds. 

This  variety  of  attacks  lasted  without  being  accompanied  by  other 
symptoms  until  January  1st,  when,  while  sitting  in  a  chair,  the  patient  ex- 
perienced a  feeling  of  numbness  in  his  left  leg,  and  told  one  of  his  sons 
to  rub  the  limb.  This  friction  caused  intense  pain,  but  the  patient  was 
speechless  and  unable  to  tell  his  child  to  stop.  Within  a  few  seconds 
afterward  he  became  unconscious,  and  tonic  convulsions  developed 
throughout  the  body.  His  wife  states  that  these  spasms  were  not  fol- 
lowed by  clonic  convulsions.  About  three  or  four  weeks  afterward,  the 
4 


50  FUNCTIONAL    NEEVOUS    DISEASES. 

patient  had  another  fit  while  in  his  shop.  For  the  first  couple  of  months 
the  attacks  of  grand  mal  came  on  about  once  a  month,  but  they  then  ap- 
peared every  two  weeks.  Until  six  months  ago,  the  attacks  of  grand 
mal  were  preceded  by  an  aura,  consisting  of  a  sensation  of  numbness  in 
the  left  leg  which  rapidly  rose  to  the  arm.  Within  the  last  six  months, 
the  fit  has  been  preceded  by  spasmodic  separation  of  the  maxillse,  so  that 
the  patient  was  unable  to  close  his  mouth,  and  by  a  queer  sensation  in 
the  head.  He  alwaj^s  has  sufficient  time  during  the  aura  to  lie  down  or 
seek  a  place  of  safety. 

With  the  exception  of  the  first  two  attacks  of  grand  mal  (occurring  in 
January  and  February,  1879),  the  paroxysms  have  been  of  a  remarkable 
nature.  The  convulsive  phenomena  corresponded  exactly  to  the  descrip- 
tion of  the  grand  mal  which  we  have  given  in  the  beginning  of  this  chap- 
ter, but  the  patient  retained  consciousness  throughout  the  tonic  and 
clonic  convulsive  stages.  According  to  both  his  own  and  his  wife's  state- 
ments, he  remembered  everything  which  had  transpired  during  the  convul- 
sions. As  soon  as  the  convulsions  ceased,  however,  he  became  comatose 
for  a  period  varying  from  five  to  fifteen  minutes,  the  eyes  being  wide 
open  during  this  period.  While  in  this  comatose  condition,  he  can  be 
partially  roused  but  does  not  comprehend  what  is  said  to  him.  About 
three  weeks  ago  (end  of  October),  the  patient  had  an  attack  in  which  he 
did  not  lose  consciousness  either  during  or  after  the  convulsions.  He  is 
now  complaining  of  intense  headache  from  which  he  has  suffered  for  the 
last  two  weeks;  he  had  a  similar  attack  in  July,  which  lasted  nearly  a  month. 
Under  the  use  of  bromide  of  potassium  in  thirty-grain  doses,  three  times 
a  day,  the  convulsions  have  ceased,  but  the  headache  from  which  he  was 
suffering  has  increased  in  intensity,  and  at  times  the  pain  is  atrocious. 
The  patient's  intellect  has  also  begun  to  suffer  ;  memory  is  impaired,  and 
at  times  he  is  almost  childish  in  his  behaviour.  The  appetite  has  become 
ravenous;  the  patient  takes  six  or  seven  meals  daily,  and  would  eat  more 
if  permitted.  The  general  phj^sical  condition  of  the  patient  is  excellent; 
no  deviations  from  the  normal  with  regard  to  motion  or  sensation,  are 
noticeable. 

As  we  have  previously  stated,  the  duration  of  the  coma  following  the 
convulsions  varies  from  a  very  few  minutes  to  upward  of  forty-eight  hours. 
There  does  not  appear  to  be  any  definite  relation  between  the  intensity  of 
the  convulsive  phenomena  and  the  duration  of  the  subsequent  coma. 
When  the  attack  occurs  during  sleep,  it  is  sometimes  difficult  to  determine 
the  difference  between  natural  sleep  and  the  epileptic  coma.  The  patients 
usually  lie  quietly,  though  sometimes  the  breathing  is  noisy;  if  spoken  to 
sharply,  or  irritated  by  a  movement,  they  may  be  partially  roused,  speak  or 
mutter  incoherently,  and  then  relapse  into  their  previous  somnolent  con- 
dition. If  left  entirely  to  themselves,  the  coma  continues  longer  than  if 
they  were  disturbed  from  time  to  time. 

As  a  rule,  the  patients  return  to  their  normal  condition  after  they  have 
recovered  from  the  coma.  Sometimes  they  feel  much  better  mentally 
than  they  did  for  some  time  prior  to  the  fit,  as  if  the  convulsion  "had 
cleared  the  brain."  In  other  cases  they  are  dull,  stupid,  and  irritable  for  a 
day  or  two,  and,  although  they  apparently  act  in  a  rational  manner,  may 
not  retain  perfect  remembrance  of  the  occurrences  during  this  period, 
thus  showing  that  consciousness  is  still  slightly  impaired.  In  more 
exceptional  cases,  the  patients  perform  a  series  of  automatic  acts  imme- 
diately after  the  cessation  of  the   coma.     One  of  my  patients,  after  she 


EPILEPSY.  51 

recovers  from  the  epileptic  coma,  begins  to  undo  her  clothes  and  goes 
about  picking  up  various  things.  I  observed  another  patient,  under  simi- 
lar circumstances,  rise  from  the  floor  and  go  to  the  door,  the  handle  of 
which  he  grasped  firmly  in  the  hand  and  rattled  violently  to  and  fro. 
When  I  approached  him  he  looked  at  me  as  if  entirely  unconscious  of  mv 
presence,  and  allowed  himself  to  be  led  to  a  seat.  In  a  few  minutes  he 
had  recovered  consciousness  and  felt  perfectly  well,  with  the  exception  of 
a  slight  dull  headache;  he  knew  nothing  of  the  occurrence  of  the  fit  until 
I  informed  him. 

The  stage  of  coma  may  also  be  immediately  followed  bv  a  condition 
of  mania,  or  this  may  not  occur  until  the  lapse  of  two  or  three  days.  We 
shall  reserve  the  discussion  of  this  feature  until  a  later  period. 

The  urine  is  usually  passed  in  increased  quantity  after  the  occurrence 
of  a  convulsion,  and  at  the  same  time  presents  a  lighter  color.  It  differs 
from  the  well-known  hysterical  urine,  however,  in  the  fact  that  the  specific 
gravity  is  not  diminished,  whereas  in  the  latter  it  becomes  considerably 
lower,  in  fact  I  have  seen  it  sink  to  1,001. 

Huppert  '  states  as  the  result  of  niunerous  investigations  that  grand 
mal  convulsions  are  invariably  followed  by  albuminuria  for  a  few  hours. 

Though  albumen  has  been  found  in  the  urine  under  such  circumstances 
by  numerous  observers,  it  does  not  by  any  means  constitute  an  invariable 
rule.  I  have  made  several  examinations  with  regard  to  this  point  and 
have  always  obtained  negative  results.  We  cannot  therefore  coincide 
in  the  view  that  a  diagnosis  of  epilepsy  may  be  excluded,  if  the  urine 
passed  after  the  suspected  epileptic  seizure  does  not  contain  albumen. 

In  some  cases  the  patient  has  no  sooner  come  out  of  one  convulsion 
that  another  one  begins,  until  finally  they  follow  one  another  in  such 
rapid  succession  that  consciousness  is  not  restored  between  t\je  attacks. 
This  constitutes  the  condition  known  as  the  status  epileptlcus  (etat  de  mal 
epileptique),  and  is  of  extremely  serious  import.  We  shall  transcribe  the 
history  of  this  affection  from  Bourneville's  article,^  which  is  probably 
the  best  treatise  on  the  subject  extant.  According  to  this  author,  the 
status  epilepticus  is  characterized:  1st.  by  the  frequent  repetitions  of  the 
fits  which  may  even  become  almost  continuous  with  one  another;  2d, 
by  a  variable  degree  of  collapse,  which  may  deepen  into  the  most  pro- 
found coma,  unattended  by  any  return  of  consciousness;  3d,  by  a  more 
or  less  complete  hemiplegia,  developing  after  a  variable  duration  of  the 
symptoms;  4th,  by  increased  frequency  of  the  pulse  and  respiration;  5th, 
by  a  considerable  elevation  of  the  temperature,  which  persists  in  the  brief 
intervals  of  the  fits. 

Bourneville  divides  the  affection  into  two  periods,  viz. :  a  convulsive 
and  a  secondary  meningitic  stage. 

The  prodromata  do  not  differ  in  any  respect  from  those  which  are  usu- 
ally experienced  by  the  patient  prior  to  his  ordinary  attacks  of  convul- 
sions. But  the  fits,  instead  of  ceasing,  follow  one  another  rapidly,  and 
before  the  epileptic  coma  has  entirely  disappeared  another  convulsion 
makes  its  appearance.  The  intervals  between  the  fits  become  shorter  and 
shorter  until  they  run  into  one  another,  and  finally  the  patient  appears 
to  be  in  one  long-continued  convulsion.  The  pulse  is  regular  but  usually 
small,  the  respirations  become  frequent  and  labored.  The  temperature 
begins  to  rise  from  the  very  beginning,  and  may  rapidly  reach  a  height  of 

'  Virchow's  Archiv.     Bd.  59,  Heffc.  3  and  4. 

'^  Etudes  cliniques  et  thermometriques  sur  les  maladies  du  systeme  nerveux,  1873. 


52  FUJ^CTIONAL    NERVOFS    DISEASES. 

104,  105,  or  107°  F.  and  upward.'  The  skin  feels  hot  and  scorching,  the 
face  is  covered  with  an  abundant  viscid  sweat.  Marked  nystagmus  is 
present,  and  the  face  and  neck  may  be  drawn  to  one  side.  The  pupils 
are  dilated  either  equally  or  unequally  on  the  two  sides,  and  do  not  react 
normally  to  light. 

After  the  convulsions  have  lasted  for  some  time,  hemiplegia  develops 
in  a  large  number  of  cases,  the  face  and  limbs  being  affected  as  in  ordi- 
nary cerebral  hemiplegia.  When  the  limbs  on  the  paralyzed  side  are 
lifted  up  and  then  allowed  to  fall  they  drop  like  inert  masses.  The  sen- 
sorial and  intellectual  functions  are  totally  abolished,  and  the  patients  lie 
in  a  profound  stupor  which  often  deepens  into  coma. 

Contracture  sometimes  occurs  and  involves  either  the  muscles  of  the 
jaw,  neck,  or  limbs.  These  contractures  are  especially  j^roduced  after  the 
cessation  of  the  fits  or  when  they  are  becoming  more  infrequent. 

Death  may  occur  in  this  stage  in  a  condition  of  extreme  cyanosis,  due 
to  the  violence  and  frequent  repetition  of  the  convulsions.  The  number 
of  the  fits  varies.  In  one  of  Bourneville's  fatal  cases  the  patient  had 
twenty  fits  on  the  first  day,  forty-five  on  the  second  day,  twenty-two  on 
the  third  day,  twenty-seven  on  the  fourth  day,  and  twelve  on  the  fifth. 

Recovery  may  also  occur  in  the  convulsive  period,  and  in  such  cases, 
of  course,  the  second  stage  is  absent. 

Secondary  or  meningitic  stage. — At  the  close  of  the  first  stage,  the 
convulsions  become  more  infrequent,  and  then  cease,  but  another  series 
of  symptoms  develops.  The  intelligence  is  more  or  less  affected,  and  the 
patient  is  in  a  state  of  hebetude  or  coma.  At  intervals  this  condition 
may  be  replaced  for  a  few  moments  by  maniacal  delirium,  which  is  often 
very  violent,  and  is  sometimes  accompanied  by  hallucinations.  The 
tongue  is  dry  and  coated,  sordes  is  found  upon  the  teeth,  and  nutrition 
is  profoundly  disturbed,  the  whole  body  becoming  rapidly  emaciated. 
At  this  time  bedsores  may  make  their  appearance,  varying  from  a  simple 
erythematous  patch  to  a  more  or  less  extensive  necrosis  of  the  skin. 

The  situation  of  these  bedsores  is  not  by  any  means  so  fixed  -as  in 
cerebral  hemorrhage  or  softening.  They  may  involve  :  1,  the  sacral 
region  ;  2,  the  buttocks;  3,  the  fold  between  the  buttocks;  4,  the  skin 
covering  the  great  trochanters.  In  addition  to  these  symptoms,  the  tem- 
perature, which  had  began  to  fall  after  the  subsidence  of  the  convulsions, 
again  rises.  The  entire  group  of  symptoms  may  now  increase  in  severity, 
the  vital  forces  rapidly  fail,  and  the  disease  progresses  to  a  fatal  termina- 
tion. Or,  on  the  other  hand,  the  collapse  diminishes,  the  functions  of 
the  skin  become  more  normal,  the  tongue  clears,  the  temperature  again 
sinks,  and  in  a  few  days  the  patient  is  restored  to  his  ordinary  condition 
of  health. 

Petit  Mal, 

This  variety  of  epilepsy  is  much  simpler  in  its  manifestations  than 
the  grand  or  haut  mal,  and  can  be  described  in  very  few  words.  The 
usual  course  of  the  affection  is  shown  by  the  following  case: 

Case  II. — C.  R.,  eet.  19  years  ;  no  hereditary  influence  discoverable. 
The  patient  had  convulsions  while  teething.     At  the  age  of  nine  years 

'  In  one  of  my  own  cases,  the  temperature  did  not  rise  above  101°  F.,  though  the 
patient  had  had  at  least  twenty-five  fits  in  rapid  succession. 


EPILEPSY.  53 

the  patient  began  masturbating  and  has  continued  the  practice  ever 
since.  According  to  her  own  admission  she  has  masturbated  once  every 
night  during  this  entire  period,  and  the  hesitating  manner  in  which  this 
statement  was  made,  led  me  to  believe  that  the  habit  was  indulged  in 
even  more  frequently.  The  epileptic  convulsions  began  when  the  patient 
was  fifteen  years  old;  during  the  first  year  of  the  disease  she  had  three 
attacks  of  grand  mal,  but  none  since  that  time.  She  has,  however,  had 
at  least  three  or  four  attacks  of  petit  mal  daily  since  her  sixteenth  year. 
These  seizures  consisted  of  a  simple  loss  of  consciousness,  attended  with 
pallor  of  the  face  ;  the  patient  would  sit  and  stare  for  a  moment,  in  an 
unconscious  condition,  and  then  immediately  recover  herself.  The 
attacks  were  frequently  observed  while  the  patient  was  sitting  at  table. 
While  engaged  in  eating,  her  face  would  grow  pale,  the  eyes  assume  a 
vacant  stare,  and  the  patient  would  become  unconscious.  If  she  had  a 
knife  or  fork  in  her  hand  at  the  time,  she  would  not  drop  it.  After  a 
few  seconds,  she  would  go  on  with  her  meals,  not  knowing  that  she  had 
had  a  seizure.  If  an  attack  occurred  while  the  patient  was  standing  or 
walking,  she  would  not  fall  or  even  totter. 

This  is  the  history  of  the  mildest  form  of  the  attack,  but  very  fre- 
quently the  disease  presents  more  marked  symptoms.  Thus,  the  dura- 
tion of  the  attack  may  be  longer  ;  instead  of  lasting  a  few  seconds, 
the  fit  may  continue  for  a  minute  or  two,  and  even  from  five  to  ten  min- 
utes, although  the  latter  period  is  extremely  rare.  At  times  the  attack 
is  preceded  by  an  aura,  though  this  does  not  assume  the  importance  that 
it  does  in  the  attacks  of  grand  mal.  The  aura  usually  consists  of  vertigo 
lasting  a  few  seconds,  or  of  an  epigastric  pain.  Sometimes  it  is  preceded 
by  an  indescribable  sensation  in  the  head.  One  patient  informs  me  that' 
he  experiences  an  indescribable,  pleasant  sensation  immediately  preceding 
the  attack.  The  seizure  may  also  be  attended  with  slight  convulsive 
movements  in  various  parts  of  the  body.  In  the  mildest  forms  they  are 
limited  to  the  face  and  consist  of  a  few  grimaces,  or  of  strabismus.  The 
friends  of  several  patients  have  informed  me  that  the  latter  performed 
peculiar  sucking  movements  with  the  lips  and  tongue  during  the  attack. 
The  following  interesting  case  illustrates  a  form  in  which  more  compli- 
cated phenomena  are  prodiiced: 

Case  III. — Charles  A.,  fet.  21  years  ;  family  history  unimportant. 
The  patient  had  convulsions  w^hen  he  was  three  or  four  years  old,  and 
these  continued  off  and  on  until  the  age  of  seven  or  eight  years,  after 
which  they  ceased.  Since  then  the  patient  has  been  very  healthy.  Dur- 
ing the  past  year,  the  patient  has  been  employed  off  and  on  in  a  lunch- 
room at  night   and  slept   during  the  day;  the  room  in  which  the  patient 

worked  was  exceedina:lv  hot.     About  ten  weeks   asro    he   first    noticed 

■       .  ... 

spells  coming  on,  attended  with  involuntary  micturition.     The   attacks 

developed  at  night  while  the  patient  was  at  work,  and  occurred  three  or 
four  times  nightly.  He  was  then  thrown  out  of  employment  for  a 
month,  and  during  this  time  the  spells  came  on  during  the  day,  the 
patient  sleeping  at  night.  The  attack  occurs  in  the  following  manner  : 
while  the  patient  is  busily  occupied,  he  suddenly,  without  any  premoni- 
tion, loses  consciousness,  his  face  reddens  and  subsequently  grows  pale, 
and  he  puts  his  hands  to  his  head  in  an  agitated  manner  ;  he  then  passes 
his  water  involuntarily.  During  the  last  week  the  patient  has  not  mic- 
turated during  an  attack.     Consciousness  is  restored  in  a  few  minutes. 


54  FUNCTIONAL    NERVOUS    DISEASES. 

There  is  no  doubt  that,  in  this  instance,  the  excessive  heat  of  the  room 
was  a  prominent  factor  in  the  causation  of  the  attacks.  In  accordance 
with  my  advice,  the  patient  changed  his  occupation,  and  this  measure 
alone  produced  a  marked  diminution  in  the  number  of  the  fits. 

This  case  differs  from  the  usual  run  in  the  fact  that  the  face  grew  red 
in  the  beginning  of  the  attack  and  then  turned  pale  ;  in  the  majority  of 
cases,  the  face  turns  pale  at  the  onset  of  the  attack  and  then,  if  the 
paroxysm  lasts  for  any  length  of  time,  grows  dark  or  dusky. 

Even  more  complicated  movements  than  those  just  referred  to  are 
performed  in  these  cases.  One  of  my  patients,  if  the  attack  occurs 
while  he  is  seated,  will  rise  from  his  chair  and  walk  around  as  if  looking 
for  something.  Cases  have  been  reported  in  which  the  attacks  occurred 
while  the  patients  were  performing  on  the  piano  or  violin,  and  in  which 
they  continued  to  play  in  time,  although  entirely  unconscious. 

We  may  also  include  in  this  category  the  cases  which  are  known  as 
epileptic  vertigo.  These  attacks  are  well  shown  in  the  history  of  the 
patient  given  on  page  49.  They  consist  merely  of  a  feeling  of  vertigo, 
usually  combined  with  faintness. 

One  feature  which  is  frequently  observed  in  this  variety  and  which  is 
extremely  important  with  regard  to  diagnosis,  is  the  fact  that  the  attack 
is  generally  preceded  by  an  aura  of  very  short  duration.  This  consists 
of  a  feeling  of  sinking  in  the  epigastrium  or  of  indescribable  anguish. 
Sometimes  the  attack  is  accompanied  by  vague  mutterings.  One  of  my 
patients  told  me  that  he  went  off  into  a  "  dream-like  "  condition,  which 
he  could  only  explain  by  saying  that  everything  around  him  appeared  as 
if  he  were  in  a  dream. 

The  paroxysms  may  alternate  with  well-marked  attacks  of  petit  mal 
or  grand  mal,  and  in  such  cases  their  nature  soon  becomes  evident.  In 
some,  however,  they  form  preliminary  symptoms  which  precede  the  de- 
velopment of  grand  mal  perhaps  by  several  years,  and  in  such  instances 
it  is  extremely  difficult  to  form  a  correct  conception  of  the  condition. 
But  we  shall  discuss  this  subject  more  hi  extenso  in  the  chapter  on 
diagnosis. 

Irregular  Epilepsy. 

This  form  of  the  disease  is  sometimes  known  as  larvated  epilepsy,  but 
we  think  the  term  is  misapplied;  the  paroxysms  are  as  distinct  as  in 
either  of  the  other  varieties,  the  only  difference  being  that  they  appear 
in  a  peculiar  form.  In  the  great  majority  of  cases,  the  seizures  are  only 
observed  in  such  patients  that  also  suffer  from  grand  or  petit  mal,  and 
some  individuals  are  exquisite  examples  of  all  the  forms  of  the  disease 
which  we  have  described.  In  very  rare  instances  the  patient  only  ex- 
periences the  irregular  paroxysms,  and  one  such  case  has  come  under  my 
notice  which  I  shall  describe  shortly. 

Hughlings  Jackson  believes  that  these  attacks  are  invariably  pre- 
ceded by  a  slight  convulsion,  but  I  cannot  agree  with  him  in  this  respect, 
basing  my  opinion  on  the  following  personal  case  : 

Case  IV, — A.  B.,  aet.  28  years;  married  five  years;  family  history 
entirely  negative;  the  patient's  general  health  has  always  been  fair; 
menses  regular  but  attended  with  a  certain  amount  of  dysmenorrhoea. 
The  patient  was  accompanied  by  her  husband,  who  desired  to  consult  me 


EPILEPSY.  55 

•with  regard  to  the  advisibility  of  sending  her  to  an  insane  asylum,  as  she 
\ras  regarded  as  insane  both  by  herself  and  husband.  After  making  a 
thorough  physical  exploration  and  finding  nothing  abnormal  in  the  thor- 
acic or  abdominal  viscera  (she  complained  of  vague  symptoms  referable 
to  these  organs),  I  began  to  make  an  ophthalmoscopic  examination.  Just 
as  I  had  brought  the  light  of  the  mirror  to  fall  upon  the  eye,  and  before 
I  could  catch  a  glimpse  of  the  fundus,  I  noticed  that  the  pupil  dilated 
to  the  utmost,  the  face  became  pale,  and  the  patient  started  back  as  if  in 
affright.  She  then  jumped  up  from  her  chair,  looked  with  a  terrified  air 
at  the  window  of  my  office  and  exclaimed,  "'Look  at  that  black  man.  He 
has  a  dagger.  He  is  going  to  kill  me."  She  then  walked  a  few  paces, 
muttering  some  inarticulate  words  and  in  a  few  moments  came  to  herself. 
The  pulse  was  unaffected  during  the  paroxysm.  After  the  seizures  the 
patient  stated  to  me  that  she  was  absolutely  unconscious  of  what  had 
transpired.  I  then  obtained  a  history  of  preceding  attacks  of  a  similar 
nature.  Thus,  on  one  occasion,  the  patient  found  herself  in  the  immedi- 
ate neighborhood  of  the  East  River,  at  a  distance  of  several  blocks  from 
her  house,  whereas  the  last  she  remembered  was  that  she  had  been  at 
home.  At  another  time  she  beat  her  husband,  to  whom  she  was  de- 
votedly attached,  although  she  was  entirely  unconscious  of  what  she  was 
doing.  Attacks  of  this  kind  had  occurred  for  three  years,  and  had  come 
on  without  any  exciting  cause.  Although  I  cross-questioned  the  patient 
and  her  husband  very  closely,  I  could  not  obtain  the  slightest  evidence 
that  she  had  ever  suffered  from  petit  or  grand  mal. 

In  this  instance  I  had  the  patient  under  observation  during  the  en- 
tire attack,  and  could  not  detect  the  slightest  spasmodic  symptoms.  The 
series  of  phenomena  manifested  in  this  variety  of  epilepsy  has  been  in- 
cluded by  Hughlings  Jackson  under  the  apt  title  of  mental  automatism, 
and  much  more  complex  acts  are  performed  than  those  reported  m  the 
history  of  the  above-mentioned  case. 

Another  very  important  peculiarity  with  regard  to  these  seizures  con- 
sists in  the  fact  that  a  thought  which  was  uppermost  in  the  mind  prior 
to  the  attack  may  exert  some  influence  upon  the  actions  performed  dur- 
ing the  unconscious  condition.  In  addition,  the  patients  may  react,  in 
a  measure,  to  something  which  is  said  or  done  by  those  around  them,  and 
this  apparently  imparts  a  certain  degree  of  volitional  character  to  their 
acts,  although  they  are,  in  reality,  profoundly  unconscious.  This  is  ex- 
emplified in  the  following  case  : 

Ca.se  V. — The  patient  in  question  was  a  young  woman,  who  suffered 
from  frequently  repeated  attacks  of  grand  mal,  and  occasionally  from 
irregular  seizures.  While  sitting  in  my  office,  I  saw  her  suddenly  rise 
from  her  chair,  walk  forward  a  few  paces,  then  turn  around  and  attempt 
to  walk  into  a  closet.  From  the  blank  expression  of  her  face  I  judged 
that  she  had  lost  consciousness.  I  walked  up  to  her  in  order  to  examine 
her  pulse  and  the  condition  of  her  pupils;  she  endeavored  to  push  away 
my  hand  as  I  tried  to  grasp  her  wrist.  I  then  ordered  her,  in  a  loud, 
peremptory  tone  of  voice,  to  sit  down,  and  my  demand  was  immediately 
complied  with.  She  remained  seated  for  about  a  minute,  muttering  some 
indistinct  words  which  I  was  unable  to  understand,  after  which  she  re- 
covered. I  inquired  whether  she  was  aware  that  she  had  had  a  fit,  and 
she  replied  in  the  negative,  stating  that  she  knew  nothing  of  what  had 
transpired. 


56  FUNCTIOIiTAL    NERVOUS    DISEASES. 

Hughlings  Jackson  '  reports  the  two  following  cases,  which  are  ex- 
tremely interesting,  with  regard  to  this  point: 

Case  VI. — "  I  was  sitting  on  his  bed  taking  his  history,  he  sitting 
by  my  side  holding  the  inkstand.  After  asking  him  a  question  and  get- 
ting no  answer,  I  looked  at  him.  He  remained  sitting,  but  his  head  was 
a  little  drooped,  and  his  face  slightly  pale.  He  still  kept  hold  of  the  ink- 
stand, and  after  a  moment  moved  as  if  to  jDut  it  down.  I  tried  to  get 
hold  of  it,  as  it  was  tilting,  but  he  pushed  me  away  with  the  other  hand. 
He  was  well  again  in  about  half  a  minute." 

In  the  other  case  reported  by  Jackson,  the  history  was  furnished  by 
the  patient. 

Case  VII. — "  My  wife  and  her  sister  being  present,  had  been  talk- 
ing about  supper,  when  it  was  agreed  that  my  wife  and  I  should  have 
some  cold  fowl,  and  the  sister  some  cocoa,  if  there  were  any  fire.  She 
went  into  the  kitchen  to  see,  and  reported  that  there  was  one.  Soon 
after  I  began  to  feel  chilly  after  being  so  warm  with  gardening,  and  I 
said  I  would  go  down  to  the  fire.  I  did  so,  and  after  standing  there  a 
few  minutes,  I  felt  symptoms  of  an  attack  and  sat  down,  I  believe,  on  a 
chair  against  the  wall.  And  here  my  recollection  failed,  the  next  thing 
I  was  conscious  of  being  the  presence  of  my  brother  and  mother  (who  had 
heen  sent  for,  as  they  lived  opposite),  and  I  have  since  been  informed 
by  my  sister-in-law  that  she  came  into  the  kitchen,  and  found  me  stand- 
ing by  the  table  mixing  cocoa  in  a  dirty  gallipot,  half  filled  with  bread  and 
milk  intended  for  the  cat,  and  stirring  the  mixture  with  a  mustard  spoon, 
which  I  must  have  gone  to  the  cupboard  to  obtain.'''' 

"  This  caused  them  to  send  for  my  friends,  to  whom  I  talked,  showing 
no  surprise  that  they  were  there,  and  entirely  unconscious  of  what  I  had 
been  doing  until  told  this  morning." 

These  cases  are  of  great  importance  from  a  medico-legal  point  of  view. 
They  prove  that  not  alone  may  the  series  of  acts  which  are  committed 
during  an  irregular  epileptic  paroxysm  appear  to  be  logically  connected 
together  as  they  are  in  healthy  individuals,  but  that  they  may  also  bear 
a  certain  relationship  to  desires  expressed  previous  to  the  occurrence  of 
the  attack.  In  the  last-mentioned  case,  the  patient  had  agreed  that  his 
sister-in-law  should  have  some  cocoa,  and  during  the  paroxysm  he  was 
found  stirring  the  cocoa,  although  he  was  entirely  unconscious  of  so 
doing.  But,  as  Hughlings  Jackson  remarks,  if  he  had  had  a  quarrel  with 
his  sister-in-law  prior  to  the  attack,  we  can  very  readily  imagine  that  this 
fact  may  have  acted  upon  him  in  his  unconscious  condition  so  as  to  lead 
him  to  commit  murder.  Kleptomania  is  not  an  infrequent  symptom  dur- 
ing these  attacks,  and  has  often  brought  the  poor  patients  in  contact 
with  the  arm  of  the  law.  It  is  very  often  extremely  difficult  to  diagnose 
this  variety,  but  we  shall  reserve  the  discussion  of  this  part  of  the  sub- 
ject to  the  chapter  on  diagnosis. 

We  will  finally  refer  to  a  number  of  conditions  which  have  lately  been 
placed  in  this  category,  and  are  known  as  epileptoid  states. 

Griesinger  *  has  called  attention  to  an  entire  group  of  cases  in  which 

'  West  Riding  Lunatic  Asylum  Med.  Rep.,  vol.  v.,  p.  105. 
*  Archiv.  f.  Psychiatric  u.  i^ervenkv.  Bd.  I. 


EPILEPSY.  57 

the  interparoxysmal  symptoms  are  those  usually  regarded  as  characteris- 
tic of  hypochondria  or  hysteria,  but  which  differ  from  the  latter  in  the 
fact  that  they  are  combined  with  vertiginous  attacks.  Griesinger  regards 
these  cases  as  examples  of  mild  epileptic  paroxysms,  and  strongly  devel- 
oped interparoxysmal  symptoms.  It  is  very  difficult  to  know  where  to 
draw  the  line.  Usually,  when  a  patient  suffers  from  the  manifold  symp- 
toms of  hypochondria,  and  complains  at  times  of  attacks  of  vertigo,  the 
latter  are  attributed  to  cerebral  congestion,  to  gastric  disturbances,  to 
constipation,  etc.  In  the  chapter  on  diagnosis  we  shall  endeavor  to  point 
out  the  way  in  which  a  distinction  may  be  made. 

Another  very  curious  phenomenon  has  recently  been  included  in  this 
group,  viz. :  paroxysmal  attacks  of  sweating.  H.  Emminghaus  ^  reports 
the  following  interesting  case: 

Case  VIII. — The  patient  was  a  woman,  forty-five  years  of  age,  whose 
courses  were  regular.  While  still  a  child  she  had  suffered  from  well- 
marked  epileptic  convulsions,  but  these  had  disappeared  spontaneously  at 
the  age  of  puberty.  For  a  few  years  past,  the  patient  has  been  attacked 
at  times  with  paroxysms  of  sweating,  which  came  on  suddenly  while  she 
was  engaged  in  some  occupation  and  without  any  apparent  cause.  These 
attacks  were  associated  with  a  feeling  of  weakness  and  slight  giddiness, 
but  after  a  few  seconds  all  the  symptoms  disappeared,  and  the  patient 
then  felt  entirely  well. 

In  conclusion  we  will  devote  a  few  lines  to  what  has  been  recently 
termed  epileptoid  "sleep-states"  (schlafzustgende).  In  1876,  Westphal 
had  called  attention  to  a  peculiar  condition  in  which  the  patient  some- 
times suddenly  lapses  into  a  doze  or  even  into  a  sound  sleep,  although 
he  had  been  entirely  wakeful  immediately  preceding  the  attack.  West- 
phal left  it  undecided  whether  this  should  be  regarded  as  an  epilep- 
toid state;  but  last  year  Franz  Fischer,  Jr.,^  reported  a  case  which  he 
thought  justified  him  in  positively  regarding  this  condition  as  truly  epilep- 
toid. In  this  case  the  patient  would  sometimes  go  off  into  a  dose  while 
standing  or  walking,  and  in  a  few  of  the  attacks  lost  consciousness  en- 
tirely. A  case  has  also  come  under  my  own  observation  which  appears 
to  favor  Fischer's  interpretation  of  this  phenomenon.  In  this  case,  which 
will  be  described  more  in  detail  in  the  chapter  on  etiology,  the  patient, 
who  also  suffered  from  undoubted  grand  mal,  on  one  occasion,  while  sit- 
ting at  table,  sank  into  a  dreamy  sleep,  which  afterward  lapsed  into 
coma.  Upon  the  restoration  of  consciousness,  the  patient  found  himself 
in  bed,  in  which  he  had  been  placed  by  his  family. 


Interparoxysmal  Condition. 

In  some  cases  the  interparoxysmal  condition  in  epilepsy  is  one  of  un- 
disturbed bodily  and  mental  health.  I  have  seen  some  instances  in  which 
men  of  fine  physical  development,  whose  general  health  was  perfectly 
normal,  suffered  from  well-marked  epilepsy,  and  I  have  sometimes 
thought  that  in  these  very  patients  the  paroxysms  were  more  severe  than 

'  Ueber  epileptoide  Schweisse,  Arch,  f .  Psych.    1873. 
2  Arch.  f.  Psych.  1878. 


58  FUNCTIONAL    NERVOUS    DISEASES. 

in  others.     Hercules  is  believed  to  have  suffered  from  this  disease,  and 
hence  arises  one  of  its  numerous  appellations. 

The  mental  condition  may  also  be  entirely  normal.  This  statement  is 
abundantly  verified  by  the  fact  that  such  great  men  as  Julius  Caesar,  Ma- 
homet, Napoleon,  Newton,  Petrarch,  Peter  the  Great,  and  many  others, 
were  afflicted  with  the  disease.  But  in  the  large  majority  of  cases  this 
does  not  hold  good.  In  very  many  individuals  the  general  health  has 
already  suffered  before  the  disease  makes  its  appearance,  and  in  some 
the  deterioration  of  health  is,  indeed,  the  exciting  cause  of  the  onset  of 
the  malady.  Sooner  or  later,  in  the  large  proportion  of  cases,  the  health 
suffers  to  a  greater  or  less  extent,  and  in  a  few  instances  I  have  noticed 
that  the  deterioration  in  health  promptly  makes  its  appearance,  even  after 
a  single  fit.  The  patients  usually  complain  of  headache  of  a  dull  charac- 
ter and  g'enerally  situated  in  the  frontal  region.  The  pain  is  not  contin- 
uous, but  does  not  remain  absent  for  more  than  a  few  days  at  the  utmost. 
In  a  few  cases  I  have  noticed  that  it  acquired  considerable  intensity,  and 
became  almost  continuous  in  character;  it  is  then  frequently  situated  in  the 
occipital  region.  We  may  sometimes  attribute  the  headache  to  the  blows 
upon  the  skull  which  the  patients  receive  during  their  frequent  falls.  The 
patients  usually  fall  in  one  direction  (very  frequently  on  the  face),  and 
after  a  while,  the  periosteum  becomes  considerably  thickened  from  the 
oft-repeated  traumatism.  Nervous  tremors  are  noticeable  in  the  muscles, 
especially  in  the  arms  and  legs,  and  are  sometimes  very  annoying.  The 
tongue  is  coated  and  the  patient  complains  of  a  bad  taste  in  the  mouth, 
and  of  oppression  in  the  epigastrium  after  eating.  As  these  unfortunates 
are,  however,  continually  taking  medicine,  I  am  inclined  to  believe  that 
the  dyspeptic  symptoms  are  due  to  the  direct  action  of  the  drugs  on  the 
gastric  mucous  membrane.  Bromide  of  potassium,  for  instance,  which  is 
now  so  generally  employed,  has  a  notoriously  bad  influence  on  the  diges- 
tive functions.  The  bowels  are  usually  confined,  and  this  is  often  one  of 
the  chief  complaints  made  by  the  patient.  Some  of  them,  in  fact,  stoutly 
affirm  that  the  constipation  exercises  a  powerful  deleterious  influence  on 
the  frequency  of  the  fits.  The  appetite  often  varies  a  great  deal,  and  is 
sometimes  very  capricious.  While  the  patients  at  times  eat  sparingly,  at 
others  they  have  a  voracious  and  ravenous  appetite. 

No  careful  investigations  have  been  hitherto  made  with  regard  to  the 
condition  of  the  pulse  and  temperature,  and  my  attention  has  not  been 
specially  drawn  in  this  direction,  but  I  have  seen  nothing  which  leads  me 
to  believe  that  there  are  any  noteworthy  disturbances  in  these  respects. 

The  general  appearance  of  confirmed  epileptics  is  often  characteristic. 
The  former  refinement  of  expression  disappears,  the  cheeks  become  puffy, 
the  lips  look  swollen  and  prominent,  the  eyes  have  a  peculiar  dull,  staring 
look  ;  in  fine,  the  lower  nature  of  the  individual  becomes  more  apparent. 
Although  this  change  of  expression  is  not  readily  expressed  in  words,  it 
is,  nevertheless,  very  characteristic,  and  a  large  experience  with  this  class 
of  patients  will  often  enable  the  physician  to  recognize  an  epileptic  at  the 
first  glance. 

The  mental  condition  presents  much  more  interesting  phenomena. 
One  of  the  first  changes  which  is  noticed  in  this  respect  is  loss  of  memory. 
As  so  frequently  happens  in  cerebral  affections,  the  memory  for  recent 
events  fails  more  quickly  than  that  for  remote  occurrences.  It  has  been 
the  generally  taught  doctrine  that  the  memory  fails  more  rapidly  in  cases 
of  petit  mal  than  in  grand  mal,  and  until  recently,  I  had  implicitly 
adopted  this  doctrine  on  trust.     But  within  the  past  year,  my  faith  has 


EPILEPSY.  59 

begun  to  waver  in  this  regard  as  I  have  seen  quite  a  number  of  striking 
exceptions  to  this  rule.  In  one  case  in  particular,  the  patient,  a  young 
woman  of  nineteen,  has  had  from  three  to  four  attacks  of  petit  mal  daily  for 
the  last  three  years,  and  I  found  her  memory  entirely  up  to  the  average, 
while  she  herself  informed  me  that  it  had  never  been  better.  I  have  seen 
quite  a  number  of  instances  of  this  kind,  though  not  so  striking,  within 
tlie  last  few  months,  but  my  attention  has  not  been  drawn  to  this  point 
sufficiently  long  to  confer  any  great  value  on  these  data. 

The  temper  also  undergoes  a  marked  change.  In  a  few  cases  the  pa- 
tients become  very  quiet  and  gentle,  but,  as  a  rule,  they  are  the  very 
reverse.  This  is  especially  noticeable  in  the  wards  of  an  epileptic  hos- 
pital. It  is  extremely  difficult  to  prevent  the  patients,  whether  male  or 
female,  from  coming  to  open  wai'fare.  They  are  continually  bickering 
and  quarrelling  on  the  slightest  pretext,  are  extremely  selfish  and  pilfer 
whatever  they  can  lay  their  hands  on.  They  are  very  anxious  for  sym- 
pathy (especially  the  female  patients),  and  feign  all  sorts  of  complaints  in 
order  to  draw  the  attention  of  the  physician  to  themselves.  Very  frequent- 
ly the  preceding  symptoms  increase  in  intensity  for  a  short  time  before  the 
fit  occurs.  After  the  fits  have  lasted  for  a  long  time,  and  especially  if  they 
occur,  as  they  often  do,  in  series  comprising  from  three  or  four  to  fifteen  or 
twenty  or  more  in  a  few  days,  the  mental  powers  gradually  deteriorate,  the 
memory  fails  almost  entirely,  the  judgment  is  lost,  and  the  patient  becomes 
entirely  demented.  In  the  latter  cases,  the  mental  decay  is  not  gradual, 
but  receives  a  considerable  and  sudden  impetus  after  each  series  of  fits. 
After  they  have  sunk  into  this  demented  condition,  the  patients  are  hope- 
lessly lost,  so  far  as  regards  their  mental  powers. 

The  discussion  of  epileptic  mental  disorders  is  really  within  the  prov- 
ince of  the  alienist,  and  I  shall  therefore  content  myself  with  giving  a 
very  brief  summary  of  the  remarks  on  this  subject  made  by  Krafft- 
Ebing, '  the  most  recent  writer  of  a  systematic  treatise  on  insanity. 
This  author  divides  epileptic  mental  disorders  into  three  classes  : 

1.  Epileptic  psychical  degeneration. 

2.  Transitory  psychical  disturbances,  usually  attended  with  delirium. 

3.  Epileptic  psychoses. 

"We  have  already  described  epileptic  psychical  degeneration  above,  so 
that  it  is  unnecessary  to  refer  to  it  again. 

The  transitory  attacks  of  psychical  disorder  may  last  from  a  few 
hours  to  several  days  ;  they  occur  either  before  or  after  the  convulsions, 
especially  after  a  series  of  attacks.  They  sometimes  develop  irrespective 
of  any  epileptic  attack  ;  consciousness  is  either  disordered  or  entirely 
lost.  The  nature  of  the  acts  performed  varies  greatly  ;  they  are  cliarac- 
terized  by  stupor  and  a  sort  of  "  somnambulistic  "  condition  (daemmer- 
zustaende). 

The  stupor  is  rarely  the  sole  symptom  ;  it  is  usually  combined  with 
frightful  delirium  and  hallucinations,  sometimes  with  exalted  religious 
ideas.  At  times,  there  are  sudden  outbreaks  of  violence,  probably  as 
the  result  of  fear. 

The  "somnambulistic"  conditions  may  occur  before  or  after  epileptic 
convulsions,  or  independently  of  them. 

They  include  several  varieties: 

1.  Petit  Mal. — This  is  characterized  by  marked  psychical  depression, 
combined  with  terror  and  confusion   of  ideas.     Under  the  influence  of 

^  Lehrbuch  der  Psychiatrie.  1879. 


60  FUNCTION" AL    NERVOUS    DISEASES. 

these  feelings,  the  patient  wanders  aimlessly  around,  believes  that  he  is 
being  pursued  by  his  enemies  and  is  destructive  to  himself  or  others. 
His  consciousness  of  the  acts  performed  while  in  this  state  is  either  par- 
tially or  entirely  lost  ;  it  is  generally  not  connected  with  any  previous 
convulsion  and  often  develops  out  of  the  condition  of  psychical  degener- 
ation found  in  chronic  epilepsy. 

2.  Grand  Mai. — This  is  a  furious  mania,  characterized  by  rapid  devel- 
opment without  any  warning  symptoms,  by  the  extreme  violence  of  the 
maniacal  acts  and  by  terrible  delirium,  in  which  fear  plays  the  chief  part. 
There  are  various  gradations  between  this  form  and  that  described  above 
as  petit  mal.  The  maniacal  condition  may  alternate  in  these  patients 
with  periods  of  profound  stupor.  Grand  mal  usually  occurs  after  con- 
vulsions, especially  when  they  have  appeared  in  a  series.  It  may  last 
from  a  few  hours  to  several  days,  and  after  its  cessation  the  patients  re- 
tain no  consciousness  of  the  occurrences  during  the  attack. 

3.  Gonditiofis  attended  with  religious  delirium. — In  this  variety,  the 
patient  considers  himself  to  be  God,  Jesus,  an  angel,  etc.,  believes  him- 
self in  heaven,  receives  communications  from  the  Deity,  delivers 
prophecies,  etc.  These  ideas  may  change,  and  the  patient  thinks  himself 
in  danger  of  eternal  damnation,  sees  the  flames  of  hell,  etc.  In  these 
cases,  consciousness  is  only  partly  clouded,  and  the  patient  retains  some 
knowledge  of  what  has  occurred  during  the  attack. 

4.  Conditions  attended  with  dream-like  ideas. — In  these  cases,  the 
patients  appear  to  those  surrounding  them  to  be  conscious  of  their  acts, 
but,  in  reality,  they  are  in  a  sort  of  somnambulistic  condition.  They  act 
under  the  influence  of  various  fanciful  notions  concerning  themselves 
and  those  surrounding  them.  In  a  case  mentioned  by  Legrand  du 
Saulle,  and  which  belongs  in  this  category,  the  patient  found  himself  on 
board  of  a  vessel  off  Bombay,  although  he  last  remembered  himself  in 
Paris.  All  his  actions  in  the  interim  had  been  a  blank  to  him.  In  a 
case  under  my  own  observation,  the  patienc  left  the  city  without  any 
object  in  view,  and  when  he  recovered  consciousness,  found  himself  in 
the  streets  of  Pittsburgh. 

Epileptic  psychoses. — Patients  suffering  from  epilepsy  may  develop 
insanity,  which  differs  in  no  respect  from  that  observed  in  other  classes 
of  patients.  But  Samt  has  shown  that  there  is  also  a  specific  form  of 
epileptic  insanity,  and  this  author  states,  "  that  every  patient  who  is  in 
a  condition  of  stupor,  kneels  in  terror  before  the  physician,  calls  him 
'  God,'  and  at  times  becomes  destructive,"  may  be  regarded  as  suffering 
from  epileptic  insanity.  Samt  divides  the  disease  into  several  varieties, 
but  the  nature  of  this  article  will  prevent  us  from  entering  any  further 
into  a  consideration  of  the  subject. 


CHAPTER  11. 

ETIOLOGY. 

Epilepsy  is  one  of  the  most  frequent  of  all  nervous  diseases.  Rey- 
nolds states  that  it  constituted  seven  per  cent,  of  all  the  cases  of  nervous 
disease  which  he  met  with  in  hospital  practice.  This  agrees  very  closely 
with  the  results  of  my  own  observation.  Among  2,299  patients  who  at- 
tended the  clinic  for  nervous  diseases  in  the  Bellevue  Out-Door  Depart- 
ment during  the  last  three  years,  156,  or  a  little  over  six  and  three-fourths 
per  cent,  suffered  from  the  various  forms  of  this  disease. 

The  causes  of  epilepsy  may  be  divided  into  two  classes,  viz.:  the  pre- 
•disposing  and  exciting. 

Predisposing  Causes. 

Heredity  undoubtedly  constitutes  the  most  important  factor  in  this 
class,  though  its  frequency  is  variously  estimated  by  different  authoi'ities. 
Delasiauve  ^  found  that  in  300  cases,  no  evidence  on  this  point  could  be 
obtained  in  167,  and  that  among  the  remaining  133  patients  there  was  a 
neuropathic  tendency  in  only  thirteen,  or  a  little  less  than  ten  per  cent. 
In  thirty-eight  cases  under  Reynolds's  ^  care,  twelve  presented  a  history 
of  nervous  disease  in  the  family,  or  a  proportion  of  thirty-one  per  cent. 
In  306  of  Echeverria's  cases,  eighty  had  a  neuropathic  family  history.  I 
ihave  notes  on  this  point  in  one  hundred  and  twenty-four  of  my  own  cases, 
and  find  heredity  as  an  etiological  factor  in  thirty  of  these  patients,  or  in 
twenty-three  per  cent. 

Gowers,'  who  has  had  an  extremely  large  experience  at  the  English 
National  Hospital  for  the  Paralyzed  and  Epileptics,  found  that  among 
1,250  epileptics,  in  whom  this  point  was  carefully  investigated,  an  heredi- 
tary neurotic  tendency  was  present  in  452,  or  thirty-six  per  cent. ;  among 
these,  the  female  sex  numbered  fifty-seven  per  cent.,  and  the  male,  forty- 
three  per  cent.  This  author  has  included  in  his  statistics  only  such  cases 
in  which  there  was  no  reason  to  suspect  cerebral  tumor,  chronic  meningi- 
tis, and  syphilitic  or  other  organic  disease. 

Martin  *  states  that  almost  all  the  children  of  epileptics  die  during  the 
first  years  of  life.  This  is  one  reason  why  the  disease  is  not  transmitted 
more  frequently,  as  it  is  to  be  presumed  that  a  considerable  proportion 
of  these  children  would  be  similarly  affected  if  they  had  lived  until  a 
more  advanced  age. 

The  powerful  influence  of  heredity  is  also  shown  by  the  fact  that 

'  Traite  de  I'epilepsie, 

® Epilepsy;  its  Symptoms,  Treatment,  etc.,  1861. 
2  British  Med.  Journal,  March  6,  1880,  et  seq. 
^  Annales  medico-psychologiques,  T.  xx.,  p.  o64. 


62  FUNCTIONAL    NERVOUS    DISEASES. 

guinea-pigs,  which  have  been  rendered  epileptic  by  experimental  means, 
may  transmit  the  disease  to  their  offspring. 

Finally,  in  estimating  the  importance  of  this  factor,  we  must  take  into 
consideration  the  fact  that  the  relatives  of  the  patient,  and  the  patient 
himself,  often  endeavor  to  conceal  the  history  of  any  antecedent  nervous 
disorder  in  the  family,  and  frequently  attempt,  by  hook  and  by  crook,  to 
adduce  some  palpable  physical  factor  as  the  cause  of  the  disease.  In  in- 
terrogating hospital  patients  we  must  also  bear  in  mind  that  stupidity 
often  reigns  supreme,  and  that  a  strict  cross-examination  may  reveal  the 
presence  of  disease  which  has  been  previously  denied. 

We  do  not  imply  by  the  term  hereditary  influence,  that  the  ancestors 
must  have  had  epilepsy.  In  fact,  any  nervous  disease  in  the  parent  may 
produce  epilepsy  in  the  children. 

Thus,  the  existence  of  hysteria,  chorea,  insanity,  obstinate  neuralgia, 
or  even  simple  nervousness  in  the  parent  may  be  transmuted  into  epilepsy 
in  one  of  the  descendants.  It  is  true,  however,  that  the  nervous  disease 
exhibited  in  the  parent  is  often  transmitted  directly  to  the  offspring. 
Thus  there  are  numerous  cases  on  record  in  which  a  tendency  to  commit 
suicide  has  been  transmitted  from  parent  to  offspring  (usually  from  father 
to  son)  for  several  generations,  and,  strange  to  say,  this  tendency  is  fre-» 
quently  manifested  at  about  the  same  period  of  life  in  all  the  individuals 
of  the  family.  But  in  many  instances,  the  neuropathic  tendency  will 
give  rise  to  the  production  of  epilepsy  in  one  child,  chorea  in  another, 
and  idiocy  in  a  third.  This  transmutation  of  disease  is  also  often  shown 
in  the  same  individual,  so  that  a  patient  who  was  choreic  in  childhood, 
becomes  epileptic  in  manhood,  and  insane  in  later  life. 

In  addition  to  these  diseases,  alcoholism  in  the  parents  may  exercise 
a  similar  baneful  influence  on  the  offspring.  Quite  a  number  of  cases  are 
recorded  in  which  the  birth  of  an  epileptic  child  was  due  to  the  occurrence 
of  conception  while  the  father  was  intoxicated.  That  this  is  not  a  mere 
coincidence  has  been  shown  by  the  fact  that  the  children  who  were  born 
later,  and  in  whom  conception  did  not  occur  under  such  circumstances, 
remained  perfectly  healthy.  In  two  of  my  cases,  also,  I  discovered  that 
the  father  was  the  victim  of  a  periodical  and  uncontrollable  desire  to 
drink,  and  that  after  such  a  debauch  had  ceased,  he  would  remain  entirely 
abstinent  until  again  seized  by  the  uncontrollable  craving.  There  is  no 
doubt  that  inebriety  may  be  transmitted,  and  I  have  myself  seen  a  few 
cases  in  which  several  examples  were  presented  in  the  same  family.  I 
also  see  no  reason  for  doubting  that  it  may  act  directly  in  the  production 
of  epilepsy  in  the  offspring.  The  hereditary  influence  sometimes  skips 
one,  and  perhaps  even  two  generations,  and  then  reappears  in  the  second 
or  third.  In  one  case  under  my  observation,  the  son  escaped,  while  of 
the  latter's  seven  children,  all  suffered  from  epilepsy.  In  another  of  my 
cases,  the  only  hereditary  history  obtainable  was  that  of  insanity  in  the 
great-grandaunt;  this  reappeared  in  two  of  the  great-grandnephews  as 
chorea  and  epilepsy  respectively. 

Some  of  the  older  authors  believed  that  phthisis  in  the  parents  is  capa- 
ble of  developing  epilepsy  in  the  progeny,  and  this  view  has  been  more 
recently  supported  by  Echeverria.  The  notion  has  probably  arisen  from 
the  great  frequency  of  phthisis;  at  all  events,  we  would  be  unwilling  to 
accept  this  statement  unless  substantiated  by  careful  statistics. 

It  would  appear  that  in  those  individuals  in  whom  the  epilepsy  is  due 
to  hereditary  influence,  the  disease  makes  its  appearance,  in  a  large  num- 
ber of  cases,  before  the  fifteenth  vear  of  life. 


EPILEPSY.  63 

Reynolds  found  that  among  twelve  patients  in  whom  an  hereditary 
taint  could  be  traced,  in  ten  the  disease  appeared  before  the  age  of  fifteen 
years,  and  in  two  between  the  ages  of  fifteen  and  twenty. 

My  own  experience  somewhat  corroborates  that  of  Reynolds.  In 
twenty-six  cases  with  a  neuropathic  family  liistory,  the  disease  developed 
nineteen  times  before  the  fifteenth  year,  five  times  from  the  fifteenth  to 
the  twenty-sixth  year.  In  one  case  the  disease  began  at  the  age  of  sixty- 
seven  years,  in  a  vigorous  man,  enjoying  excellent  health.  In  this  pa- 
tient, the  hereditary  taint  was  shown  by  the  development  of  insanity  in 
two  cousins. 

Gowers  has  drawn  different  deductions  from  his  statistics,  and  has 
come  to  the  conclusion  that  heredity  possesses  very  little  less  influence 
in  the  production  of  epilepsy  during  adult  life  than  it  does  in  childhood. 
This  is  so  contrary,  however,  to  the  general  opinion  of  the  great  mass  of 
observers,  that  we  are  unwilling  to  accept  this  opinion  unless  substan- 
tiated by  the  experience  of  others. 

From  a  careful  analysis  of  his  cases,  Reynolds  concludes  "that  here- 
ditary taint  is  not  Avithout  influence  upon  the  character  of  the  attacks; 
but  that  the  influence  it  exerts  is  favorable  to  the  development  of  epilep- 
sia gravior,  rather  than  epilepsia  mitior." 

I  will  conclude  my  remarks  on  heredity  by  giving  the  family  history 
of  an  interesting  case  under  my  observation.  The  father  was  a  periodi- 
cal drinker;  by  his  first  wife  (who  was  healthy)  he  had  four  children,  two 
daughters,  one  of  whom  was  insane,  and  another  imbecile  (neither  of 
these  had  children);  and  two  healthy  sons,  one  of  whom  had  an  epi- 
leptic, and  the  other  an  insane  child.  By  the  second  wife  (also  healthy) 
he  had  three  sons,  one  of  whom  died  of  epilepsy,  and  another  was  epilep- 
tic, and  had  an  insane  child;  the  third  son  was  healthy  and  had  seven 
children.  All  of  these  had  fits  in  infancy  ;  one  was  a  confirmed  epileptic, 
and  another  suffered  from  epileptic  insanity. 

Sex. — The  prevailing  opinion,  especially  among  the  older  writers,  has 
been  that  the  disease  is  more  common  among  females  than  among 
males.  Several  of  the  more  recent  authors,  however,  are  opposed  to  this 
view.  Among  eighty-eight  cases,  Reynolds  found  forty -nine  males  and 
thirty-nine  females.  Eulenburg  *  found  seventy-three  in  males,  and  fifty- 
nine  in  females;  Nothnagel  states  that  it  occurs  in  about  equal  frequency 
in  both  sexes.  I  have  observed  seventy-five  cases  in  males  and  fifty-nine 
in  females.  Gowers,  whose  statistics  include  1,450  cases,  found  that  there 
were  114  females  to  100  males;  after  the  age  of  thirty  years,  however, 
the  proportion  of  males  is  greater  than  that  of  females,  and  this  disparity 
increases  after  forty.  It  is  evident,  therefore,  that  sex  possesses  very 
little,  if  any,  influence  on  the  development  of  the  disease. 

Age. — This  factor  is  more  important  as  an  etiological  element  than 
the  preceding  one.  In  Reynolds's  experience,  the  disease  appeared  in 
forty-eight  patients  during  the  first  seventeen  years  of  life,  in  fourteen 
.between  the  ages  of  seventeen  to  twenty  years,  and  in  fourteen  from  the 
ages  of  twenty-one  to  seventy  years.  Among  Gowers's  patients,  12^  per 
cent,  began  during  tlie  first  three  years  of  life,  29  per  cent,  in  the  first 
ten  years,  46  per  cent,  between  the  ages  of  ten  and  twenty  years,  and 
15.7  percent,  between  the  ages  of  twenty  and  thirty  years.  In  my  own 
cases,  I  found  that  among  ninety-three  patients,  the  disease  appeared  in 
the  first  seventeen  years  of  life  in  fifty-seven  patients,  from  seventeen  to 


'  Lehrbuch  der  Nervenkraakheiten.    1878. 


64  FUNCTIONAL    NERVOUS    DISEASES. 

thirty  years  in  sixteen,  and  from  thirty  to  sixty-seven  years  in  twenty 
individuals.  It  has  been  supposed  that  the  later  the  disease  makes  its 
appearance  the  more  is  it  due  to  causes  other  than  heredity,  although,  as 
we  have  seen,  Gowers  holds  to  the  opposite  opinion.  In  the  twenty 
patients  in  whom  it  first  appeared  between  the  ages  of  thirty  to  sixty- 
seven  years,  in  nine  no  cause  could  be  obtained,  in  two  it  was  due  to 
traumatism,  in  two  to  syphilis,  in  two  to  alcoholism,  in  one  to  sexual  ex- 
cess, and  in  one  each  to  exposure,  fright,  heredity,  smoking.  This  ex- 
hibit runs  counter  to  the  current  opinion  according  to  which  the  develop- 
ment of  epilepsy  after  the  thirtieth  year  of  life  is  usually  an  indication  of 
cerebral  syphilis. 

I  must,  however,  mention  in  this  connection  that  I  have  omitted  from 
the  category  of  syphilitic  epilepsy,  all  those  cases  in  which  the  patients 
presented  other  well-marked  tumor  symptoms,  such  as  paralysis  of  the 
ocular  muscles,  facial  paralysis,  atrophy  of  the  optic  nerves,  etc. 

It  is  well  also  to  be  on  our  guard  when  confronted  with  epilepsy  which 
has  developed  late  in  life,  lest  the  epilepsy  is  only  one  symptom  of 
some  organic  cerebral  affection,  and  the  older  the  patient  is  at  the  onset 
of  the  disease,  the  more  careful  must  be  our  search  for  other  symptoms. 
In  two  of  my  cases,  however,  the  disease  first  appeared  at  the  ages  of 
fifty-seven  and  sixty-seven  years  respectively,  and  their  course  showed 
that  they  were  evidently  idiopathic  epilepsy.  In  the  former  case  the 
patient,  who  was  in  tolerable  health  and  presented  an  excellent  family  his- 
tory, worried  a  great  deal  aVjout  the  intended  removal  of  her  daughter 
from  the  city,  and  on  the  very  day  of  her  departure,  the  patient  had  the 
first  attack  of  grand  mal.  The  attacks  then  occurred  at  irregular  inter- 
vals during  the  next  two  years  until  she  came  under  my  care.  Under  the 
use  of  bromide  of  potassium,  the  convulsions  entirely  ceased  and  have  not 
returned  for  the  past  year.^ 

The  second  patient,  a  healthy  farmer,  in  whom  the  only  etiological 
factor  obtainable  was  insanity  in  two  cousins  (showing  the  presence  of 
an  hereditary  taint),  had  the  first  attack  at  the  age  of  sixty-seven,  aftgr 
which  they  appeared  at  short  intervals  for  three  years.  During  this 
period  he  had  upward  of  150  attacks,  all  of  them  being  well-marked 
paroxysms  of  grand  mal.  For  nearly  a  year  the  patient  suffered  from 
epileptic  mania,  and  was  very  violent,  excitable,  and  destructive.  The 
last  attack  occurred  during  the  summer  of  1877,  and  since  that  time  the 
patient  has  been  in  excellent  health,  with  the  exception  of  an  attack  of 
bronchitis,  and  his  previous  mental  condition  has  been  entirely  restored. 

Reynolds  mentions  a  case  of  pure  epilepsy  which  developed  at  the  age 
of  seventy-one,  and  Heberden  another  at  seventy-five.  Other  cases  have 
been  reported  at  such  an  advanced  age,  but  they  form  decided  exceptions. 

We  shall  now  direct  our  attention  to  the  accidental  or  exciting  causes, 
which  are  much  more  numerous  than  the  predisposing. 

Alcoholism. — This  is,  on  the  whole,  a  very  infrequent  cause  of  the 
disease,  and  was  observed  in  few  of  my  cases.  Among  608  cases  ana-, 
lyzed  by  Gowers  with  reference  to  etiology,  only  thirteen  were  trace- 
able to  chronic  alcoholism.  Alcoholic  epilepsy  may  develop  either  in  in- 
dividuals who  are  in  a  continual  state  of  semi-intoxication  or  in  those 
who  go  on  occasional  sprees,  which  terminate  in   mild  delirium  tremens. 

'  As  this  book  is  going  through  the  press,  the  patient  died  with  symptoms  which 
I  referred  to  a  fatty  and  dilated  heart.  Unfortunately  I  was  unable  to  obtain  an 
autopsy. 


EPILEPSY.  65 

We  must,  however,  exercise  caution  in  pronouncing  drink  an  etiological 
factor.  In  one  instance  a  patient  was  referred  to  nie  by  a  medical  friend 
as  a  case  of  alcoholic  epilepsy,  but,  upon  careful  questioning,  I  found 
that  although,  at  the  present  time,  the  fits  only  appeared  when  the  pa- 
tient went  on  a  spree,  the  attacks  had  occurred  during  childhood,  and  that 
there  was  an  hereditary  taint  in  the  family.  Cases  of  this  kind  are  not 
unfrequently  observed,  and  I  have  several  times  noticed  tliat  in  patients 
in  whom  the  disease  had  been  latent  for  several  years,  the  fits  again  re- 
curred with  the  former  frequency,  after  the  patient  had  been  drinking 
heavily  for  some  time.  In  the  majority  of  my  cases,  the  attacks  which 
were  brought  on  by  drunkenness  occurred  during  the  night,  and  were 
always  of  the  nature  of  grand  mal.  Magnan  has  shown  that  absinthe 
possesses  a  great  influence  on  the  production  of  epilepsy,  but  Legrand 
du  Saulle  believes  that  the  nature  of  the  stimulant  is  immaterial,  that 
brandy,  whiskey,  and  wine  are  alike  potent  in  this  regard;  this  author 
regards  the  alcohol  as  the  only  efficient  factor.  I  am  unable  to  offer  any 
opinion  upon  this  question,  as  the  only  cases  which  have  come  binder 
my  notice,  in  which  the  convulsions  could  be  attributed  to  intoxication, 
were  due  to  drinking  whiskey,  brandy,  or  beer.  Fortunately,  the  habit 
of  drinking  absinthe  has  not  found  much  favor  in  this  country,  and  we 
will  therefore  be  unable  to  institute  any  comparisons  between  its  effects 
and  those  of  the  stimulants  habitually  drunk  here. 

Sextial  excesses. — In  one  of  my  cases,  sexual  excess  constituted  the 
only  traceable  cause.  The  patient,  a  middle-aged  man,  had  had  inter- 
course six  or  seven  times  a  week  since  early  manhood,  had  a  perfect  fam- 
ily history,  and  was  entirely  well  in  all  other  respects.  The  older  authors 
laid  great  stress  upon  this  factor  as  well  as  upon  sexual  continence  and 
masturbation,  as  active  causes  of  epilepsy.  The  activity  of  these  causes 
has  been  greatly  exaggerated,  especially  with  reference  to  masturbation. 
A  very  intelligent  and  observant  patient  in  the  male  pavilion  of  the  Epi- 
leptic and  Paralytic  Hospital,  told  me  that  all  the  patients  in  the  ward 
practised  masturbation,  himself  included,  but  that  he  had  only  begun  the 
habit  after  he  was  attacked  with  epileps3\  The  reason  that  the  practice 
is  so  widespread  in  an  epileptic  hospital  is  obvious.  The  disease  itself 
produces  a  depression  of  the  moral  stamina  of  the  patients,  and  the  char- 
acter of  the  affection  prevents,  in  great  part,  the  exercise  of  the  sexual 
functions  in  the  natural  manner.  My  own  observation  in  the  female 
pavilion  of  the  hospital  has  also  taught  me  that  masturbation  is  very  ex- 
tensively practised  by  female  epileptics.  But  these  facts  are  far  from  in- 
dicating that  the  masturbation  was  the  cause  of  the  epileptic  attacks.  Al- 
though I  have  carefully  investigated  this  phase  of  the  question  for  several 
years  past  at  my  clinic  in  the  Bellevue  Out-Door  Department  (in  which  the 
facilities  for  such  investigations  are,  of  course,  much  greater  than  in  pri- 
vate practice),  I  have  been  unable  to  find  a  single  case  of  epilepsy  which 
I  could  with  justice  attribute  to  this  cause.  When  tempted  to  believe  that 
a  case  of  epilepsy  is  due  to  this  habit,  we  should  bear  in  mind  how  com- 
mon the  practice  is  among  the  young  of  both  sexes,  and  that,  if  the  soli- 
tary vice  possessed  any  marked  degree  of  influence  on  the  development  of 
epilepsy,  the  latter  disease  should  be  much  more  frequent  than  it  really  is. 
I  remember  one  patient,  a  maiden  lady,  thirty-one  years  old,  who  confessed 
to  me  that,  since  the  age  of  nine  years,  she  had  masturbated  at  least  once 
every  night.  The  only  effect  produced  on  this  patient  was  the  develop- 
ment of  symptoms  of  nervous  exhaustion,  or,  as  it  is  now  fashionably 
termed,  cerebral  neurasthenia. 


Q6  FUNCTIONAL    ITERVOUS   DISEASES. 

In  a  few  instances  the  first  epileptic  convulsion  has  occurred  during 
the  performance  of  the  sexual  act  and  only  appears  when  sexual  inter- 
course is  attempted.  This  occurs  both  in  males  and  females,  and  is  some- 
times observed  when  the  genital  organs  appear  to  be  entirely  normal. 
In  rare  cases  this  is  due  in  the  female  to  the  irritation  of  hypersensitive 
portions  of  the  genital  tract,  but  these  cases  really  belong  to  the  category 
of  reflex  epilepsy,  and  will  be  discussed  under  that  heading.  As  a  rule, 
the  convulsions  which  at  first  only  occur  during  the  sexual  act,  afterward 
appear  apart  from  this  exciting  cause,  and  the  disease  then  runs  the 
course  of  ordinary  epilepsy.  But,  even  in  cases  of  this  character,  we 
should  always  carefully  examine  the  patients  with  regard  to  the  presence 
of  some  hereditary  predisposition. 

A  few  cases  have  been  reported  by  trustworthy  observers  in  which  the 
epileptic  attacks  appeared  to  be  due  to  the  irritability  produced  by  abso- 
lute continence,  and  in  which  marriage  and  regular  sexual  intercourse 
caused  the  disappearance  of  the  disease.  But  these  examples  are  very 
exceptional  and  they  should  not  lead  us  to  advise  matrimony  in  young 
unmarried  epileptics  of  either  sex.  We  must  remember  that  even  though 
marriage  prove  remedial  in  the  parent,  the  disease  or  some  other  neurosis 
may  be  transmitted  to  the  offspring  of  such  a  union.  At  all  events  the 
patient  should  be  informed  of  the  possibility  of  such  an  occurrence,  and 
the  responsibility  of  the  decision  thrown  upon  his  own  shoulders.  It  is 
unnecessary  to  state,  however,  that  patients  will  rarely  be  deterred  from 
marriage  by  the  possibility  of  a  contingency  of  this  nature. 

Hejiex  epilepsy. — In  ten  of  my  cases  the  disease  was  due  to  reflex 
causes,  which  consisted:  in  six  cases  of  injuries  to  the  head;  in  three,  to 
various  other  parts  of  the  body  (leg,  abdomen,  back);  and  in  one,  to  preg- 
nancy. In  one  instance  the  causal  relation  between  the  injury  and 
the  development  of  the  epilepsy  was  ver}^  evident.  The  patient  in  ques- 
tion was  a  young  man,  nineteen  years  of  age,  who  presented  no  ascer- 
tainable hereditary  taint,  and  had  shown  no  evidences  of  nervous  dis- 
ease until  the  age  of  two  years,  when  he  fell  from  a  carriage,  striking 
upon  his  head.  He  was  rendered  unconscious  by  the  blow  for  upward 
of  an  hour  and  a  half,  and  the  same  night  was  attacked  by  an  epileptic 
convulsion.  These  attacks  recurred  at  intervals  until  the  age  of  seven 
years,  at  which  period  they  ceased  entirely  and  remained  absent  until  the 
age  of  seventeen  (two  years  ago)  ;  during  this  time  the  patient  enjoyed 
excellent  health.  He  then  had  another  fall  upon  the  head,  after  which 
the  epileptic  attacks  reappeared  and  have  continued  up  to  the  present 
time.  As  a  rule,  epilepsy  will  not  develop  from  a  blow  upon  the  head, 
unless  the  injury  has  been  sufficiently  severe  to  produce  unconsciousness 
for  a  considerable  period. 

In  one  instance,  in  which  I  succeeded  in  obtaining  an  autopsy,  the 
affection  was  caused  by  the  pressure  of  exostoses  upon  the  brain.  These 
growths,  which  measured  about  an  inch  in  length  at  their  base  and  three- 
fourths  of  an  inch  in  thickness,  projected  from  the  frontal  bone  and  were 
symmetrically  situated  on  each  side  of  the  falx  cerebri  ;  they  had  pro- 
duced corresponding  depressions  in  the  anterior  portions  of  the  superior 
and  middle  frontal  convolutions.  The  only  nervous  symptoms  existing 
during  life  consisted  of  the  epileptic  attacks;  the  patient  died  of  peri- 
carditis and  fatty  degeneration  of  the  heart. 

Similar  results  may  follow  from  depression  of  the  skull,  and  from  irri- 
tation of  the  dura  mater  or  surface  of  the  brain  by  a  splinter  of  bone. 
Epilepsy  is  also  not  uncommonly  observed  in  pachymeningitis,  cerebral 


EPILEPSY.  67 

gummata,  and  other  tumors  of  the  brain,  especially  when  they  are  situated 
on  the  anterior  portions  of  the  convexity.  But  in  these  cases,  the  epi- 
lepsy is  usually  combined  with  other  cerebral  symptoms,  to  which  we  shall 
refer  in  the  chapter  on  diagnosis.  In  one  patient,  the  disease  began  a 
year  and  a  half  after  an  attack  of  cerebral  hemorrhage,  but  the  previous 
history  was  so  indefinite  that  I  am  unable  to  state  positively  whether  the 
latter  affection  acted  as  a  cause  of  the  epilepsy. 

Injuries  of  the  peripheral  nerves  also  act  as  etiological  factors.  This 
is  usually  due  to  lesions  of  the  sensory  and  mixed  nerves,  but  cases  have 
also  been  reported  in  which  the  epilepsy  was  secondary  to  an  affection  of 
purely  motor  nerves.  In  these  cases  neuritis  almost  always  develops  ia 
the  injured  nerves,  and  neuromata  are  sometimes  observed  upon  them. 

Thus,  in  one  case  the  disease  followed  the  development  of  a  neuroma 
in  an  amputation  stump.  In  a  case  which  came  under  my  observation, 
the  epilepsy  developed  after  an  injury  to  the  outer  aspect  of  the  left 
leg;  no  symptoms  of  neuritis  were  manifested  at  any  time.  The  epi- 
leptic attacks  were  always  preceded  by  a  motor  aura  which  began  in  the 
injured  leg  and  rapidly  spread  up  the  left  side  of  the  body.  Although 
there  was  no  pain  or  tenderness  over  the  injured  part,  the  convulsions 
rapidly  became  more  infrequent  from  the  local  application  of  the  con- 
stant galvanic  current  three  times  a  week.  I  lost  sight  of  the  patient, 
however,  within  a  couple  of  months  after  beginning  the  treatment,  and 
lam  therefore  unable  to  report  upon  the  final  termination. 

These  cases  form  the  analogues  of  the  epilepsy  produced  in  various 
animals,  especially  guinea-pigs,  by  certain  experimental  procedures,  such 
as  blows  on  the  head,  section,  or  other  injuries  of  the  peripheral  nerves, 
etc.,  and  which  we  shall  describe  at  a  later  period  in  the  chapter  on  path- 
ology. As  in  animals,  the  cases  in  man  which  are  due  to  traumatism 
present,  in  extremely  rare  cases,  an  epileptogenic  zone,  i.e.,  a  region  whose 
irritation  will  give  rise  to  the  production  of  an  epileptic  convulsion.  My 
own  cases  did  not  present  this  symptom,  and  I  shall  therefore  give  the 
following  abstract  of  a  very  interesting  observation  of  this  nature  reported 
by  Dr.  Neftel.' 

Case  IX. — H.  W.  K.,  fct.  24  years,  entirely  free  from  any  neuro- 
pathic tendency;  was  previously  in  perfect  health.  In  July,  1869,  he  was 
struck  on  the  head,  during  a  riot,  with  a  loaded  cane.  He  fell  senseless  to 
the  ground  and,  while  in  this  condition,  received  several  more  blows  upon 
the  skull.  The  first  blow  struck  the  right  side  of  the  forehead  over  the 
frontal  eminence,  but  no  external  marks  of  contusion  were  present.  The 
patient  remained  unconscious  for  seventy-two  hours.  During  the  second 
week  after  the  injury  he  remained  very  feeble,  and,  after  the  slightest  ex- 
ertion, lost  consciousness,  which  remained  suspended  for  ten  minutes  and 
was  attended  with  epileptic  convulsions.  After  the  lapse  of  three  months 
the  patient  began  to  w^alk  about,  but  had  several  attacks  while  in  the 
street. 

He  began  to  suffer  from  headache  as  soon  as  consciousness  had  been 
restored  after  the  accident,  and  this  has  continued  uninterruptedly  ever 
since.  The  pain  is  situated  on  the  right  side  of  the  forehead  and  in  the 
right  eye,  the  most  sensitive  part  being  the  right  external  frontal  crest. 
^  considerable  pressure  is  made  over  the  sensitive  zone,  the  pains  become 
intensified  to  an  intolerable  degree,  and  the  patient  falls  to  the  ground  in 

'  Arch,  fur  Psychiatrie.  VII,  1877,  p.  124. 


68  FUNCTIONAL    NEEVOUS   DISEASES. 

an  unconscious  condition^'  co7ivulsions  then  make  their  appearance  lohich 
were  regarded,  by  the  physicians  who  sate  them,  as  ejnleptic  in  character. 
At  rare  intervals,  attacks  of  unconsciousness  develop,  although  no  pres- 
sure has  been  made  upon  the  epileptogenic  zone.  During  the  spontaneous 
pains,  the  skin  of  the  painful  region  is  analgesic. 

This  patient  was  treated  by  local  applications  of  galvanism,  which  soon 
produced  a  remarkable  improvement,  but  Dr.  Neftel  lost  sight  of  him 
after  the  current  had  been  applied  thirty-one  times. 

Dr.  Neftel  believes  himself  "  justified  in  concluding,  or  at  least  in  sur- 
mising, that  those  cases  of  epilepsy,  in  which  an  epileptogenic  zone  is 
present,  have  been  caused  by  traumatism."  The  case  at  least  teaches  us, 
apart  from  its  intrinsic  interest,  to  exercise  great  care  in  an  examination 
of  patients  suffering  from  traumatic  epilepsy  in  searching  for  the  pres- 
ence of  an  epileptogenic  zone.  This  remark  is  especially  applicable  with 
regard  to  the  epilepsy  of  young  children,  who  so  frequently  suffer  from 
blows  on  the  head. 

In  a  certain  number  of  cases  epilepsy  is  due  to  teething.  Gowers 
found  that  among  180  cases  beginning  during  the  first  three  years  of  life, 
seventy-two  developed  during  dentition.  We  not  infrequently  notice 
that  epileptics  have  suffered  from  eclamptic  attacks  during  the  period  of 
dentition,  and  some  authors  believe  that  frequently  recurring  eclamptic 
convulsions  may  produce  an  "  epileptic  habit "  in  the  brain  and  thus  give 
rise  to  the  independent  existence  of  epilepsy.  But  the  eclampsia  of  child- 
hood is  so  overwhelmingly  more  frequent  than  epilepsy  that  we  are  very 
skeptical  with  regard  to  its  efficiency  as  a  cause  of  the  latter  affection. 

Diseases  of  almost  all  the  organs  of  the  body  may  act  as  exciting  causes 
of  epilepsy.  Several  cases  are  reported  in  which  various  affections  of  the 
ear  acted  in  this  manner.  Fabrice  de  Hilden  reported  a  case  in  which 
epilepsy  was  due  to  the  presence  of  a  glass  bead  in  the  ear  and  was  cured 
by  its  removal.     Schwig  '  reports  the  following  interesting  example: 

Case  X. — The  patient  was  eleven  years  old;  one  year  and  a  half  pre- 
viously he  fell  from  a  baby  carriage,  struck  upon  the  right  cheek  and 
ear,  and  was  dragged  along  for  a  short  distance  on  a  gravel  road.  Dur- 
ing the  next  few  days  the  patient  complained  of  slight  stitches  in  the 
right  ear,  and  five  or  six  weeks  later,  an  epileptic  ccnvulsion  suddenly 
developed  without  any  warning.  The  child  had  been  very  quiet  and  sub- 
dued since  the  accident,  in  contrast  to  his  former  lively  spirit.  The  epilep- 
tic attacks  were  repeated  at  varying  intervals.  Upon  examining  the  ear, 
the  auditory  canal  was  found  entirely  occluded  by  a  hard  substance.  The 
mass  was  removed  by  a  pair  of  forceps,  and  during  this  operation  the 
patient  was  seized  with  a  convulsion;  in  the  centre  of  the  mass  was 
found  a  small  stone  with  sharp  angles.  A  period  of  ten  months  has 
elapsed  since  the  removal  of  the  foreign  body,  during  which  no  convul- 
sion occurred.  The  boy,  who  was  previously  pale  and  had  a  stupid  ex- 
pression of  countenance,  is  now  the  picture  of  health. 

Moos'*  has  entered  fully  into  the  literature  of  this  subject,  and  from 
his  article  it  appears  that,  apart  from  foreign  bodies  in  the  ear,  epilepsy 
may  also  be  produced  by  inflammatory  affections  of  the  middle  ear,  and 
caries  of  the  bones  of  the  ear. 

•  Archiv  f.  Ohrenheilkunde.     Bd.  XIY.  1878. 
"^  Arch,  f .  Augen  u.  Ohrenheilk.  IV.  2. 


EPILEPSY.  69 

Affections  of  the  respiratory  passages  may  also  give  rise  to  epilepsy. 
Sommerbrodt '  reports  a  case  in  which  epilepsy  was  caused  by  the  pres- 
ence of  a  fibroma  on  the  left  vocal  cord,  and  in  which  the  attacks  ceased 
after  the  extirpation  of  the  tumor.  Charpigiion'  observed  a  case  in  which 
a  foreign  body  in  the  bronchi  produced  epilepsy.  Charcot  observed  epi- 
leptic attacks  in  an  old  man  suffering  from  chronic  bronchitis  and  emphy- 
sema, in  whom  the  attacks  were  always  preceded  by  a  dry  cough  and  a 
feeling  of  titillation  in  the  neck  below  the  larynx. 

Epilepsy  also  appears  to  be  connected,  in  some  instances,  with  disorders 
of  the  female  genital  apparatus.  Numerous  gynaecologists  believe  that 
amenorrhoea  is  a  not  infrequent  cause  of  epilepsy.  Graily  Hewitt '  men- 
tions an  interesting  case  of  this  kind,  in  which  the  fits  ceased  upon  the 
appearance  of  the  first  menstrual  epoch.  1  have,  however,  seen  so  many 
cases  in  which  epilepsy  developing  during  childhood  was  combined,  at 
the  age  of  puberty,  with  amenorrhoea,  and  in  which,  at  a  still  later  period, 
the  menses  appeared  and  continued  regularly  without  any  apparent  effect 
upon  the  frequency  of  occurrence  of  the  epileptic  convulsions,  that  I 
have  become  somewhat  skeptical  as  to  the  existence  of  any  causal  rela- 
tion between  the  two  affections.  The  period  of  menstruation  frequently 
has  considerable  influence  on  the  occurrence  of  the  convulsions.  Some- 
times they  develop  immediately  prior  to  the  establishment  of  the  men- 
strual discharge,  at  others  they  do  not  appear  until  the  latter  has  lasted 
for  a  few  days.  I  have  found,  however,  as  a  general  rule,  that  even  when 
the  epileptic  attacks  were  at  first  connected  with  the  menses,  they  oc- 
curred independently  of  them  after  the  disease  had  lasted  for  a  certain 
length  of  time. 

In  one  case  the  convulsions  appeared  to  be  due  to  anteversion  of  the 
uterus,  as  they  disappeared  after  the  organ  was  restored  to  its  normal  po- 
sition. In  the  following  case,  the  epilepsy  seemed  to  be  the  result  of  the 
reflex  irritation  caused  by  the  presence  of  a  foetus  in  utero. 

Case  XI. — Elizabeth  W.,  fet.  18  years,  single;  no  hereditary  influence. 
When  six  years  old  the  patient  had  scarlatina,  and  since  then  has  been  per- 
fectly well  until  the  beginning  of  this  year  (this  history  was  taken  Septem- 
ber 5,  1876).  She  began  to  menstruate  at  the  age  of  fourteen  years,  and 
the  courses  have  always  been  regular.  On  February  1 ,  1876,  the  patient  was 
attacked  with  diphtheria  in  a  very  severe  form,  which  was  attended  with 
regurgitation  of  fluids  through  the  nostrils.  She  had  recovered  by  the  1st 
of  April.  After  recovery,  the  patient  took  a  walk  one  afternoon  in  the 
month  of  May,  and  states  that  she  then  caught  cold.  The  same  after- 
noon she  had  the  first  epileptic  attack  (grand  mal),  followed  by  another 
one  during  the  night.  On  the  next  day  there  was  a  recurrence  of  the 
diphtheria,  and  during  the  entire  period  of  this  relapse  she  had  quite  a 
number  of  convulsions.  Since  then  she  has  had  them  almost  every  night, 
and  often  also  in  the  day-time,  with  the  exception  of  three  and  a  half 
months,  from  the  middle  of  May  until  September  1st,  during  which  time 
she  was  in  the  country  and  only  had  two  fits.  Since  September  1st  she 
has  had  them  every  day  and  night — sometimes  as  many  as  two  in  the 
afternoon  (never  in  the  morning)  and  three  or  four  at  night. 

Upon  physical  examination  the  patient  was  found  to  be  in  the  fourth 
month  of  pregnancy,  and  upon  comparing  the  dates  of  the  cessation  of 

>  Berl,  Klin.  Wochenschr.  1876.  « Gaz.  des  hopitaux,  1876. 

=*  Diseases  of  Women,  1874,  p.  437. 


70  FUNCTIOITAL   NERVOUS   DISEASES. 

the  menses  and  the  appearance  of  the  first  fit,  it  was  found  that  the  lat- 
ter had  developed  within  a  couple  of  weeks  after  impregnation  had  oc- 
curred. At  the  time  of  the  first  convulsion  the  patient  was  unaware  of 
her  condition,  so  that  the  attack  could  not  have  been  due  to  worry  on 
this  account.  Since  her  knowledge  of  this  fact,  however,  she  has  been 
exceedingly  worried,  and  this  has  undoubtedly  had  considerable  influ- 
ence on  the  frequency  of  the  fits.  I  kept  the  patient  under  observation 
until  she  had  reached  the  middle  of  the  seventh  month  of  pregnancy;  during 
this  entire  time  the  urine  had  been  carefully  examined  on  several  occa- 
sions with  entirely  negative  results.  During  the  last  month  the  patient's 
memory  became  worse  and  her  general  mental  condition  failed  some- 
what. I  then  consulted  two  eminent  gynsBcologists  as  to  the  propriety 
of  bringing  on  premature  labor,  which  I  believed  justifiable.  My  consul- 
tants, however,  entertained  a  diiferent  opinion,  and  my  suggestion  was 
not  carried  out.     Soon  after  I  lost  sight  of  the  patient. 

It  may  be  claimed  that,  in  this  case,  the  disease  was  due  to  the  diphtheria, 
but  I  doubt  this,  for  the  following  reasons:  In  the  first  place,  the  pa- 
tient had  entirely  recovered  from  the  diphtheria  at  the  time  of  the  first 
convulsion;  secondly,  the  convulsions  began  within  a  couple  of  weeks 
after  impregnation;  and  finally,  they  increased  in  frequency  toward  the 
end  of  pregnancy.  The  latter  fact  was  not  due  to  the  increased  worry, 
as  latterly  the  patient  was  becoming  reconciled  to  her  lot,  her  condition 
was  unsuspected  by  her  family,  and  she  had  made  arrangements  to  be 
confined  in  a  neighboring  city,  in  order  to  obviate  risk  of  detection. 

Rosenthal  ^  mentions  a  striking  case  of  reflex  epilepsy,  relieved  by 
local  treatment. 

Case  XII. — "  A  young  woman,  twenty-four  years  of  age,  who  had 
been  previously  healthy,  suffered,  at  the  end  of  the  fourth  month  of  mar- 
riage, after  the  performance  of  the  sexual  act,  from  acute  pains  in  the  ab- 
domen, which  were  soon  attended  by  convulsions,  combined  with  loss  of 
consciousness.  During  the  following  weeks  the  patient  abstained  from 
coitus  and  enjoyed  perfect  health.  When  she  again  indulged  in  sexual 
intercourse  the  epileptic  seizures  returned  and  soon  began  to  occur  spon- 
taneously^  at  first  only  at  the  menstrual  epochs,  and,  at  a  later  period,  ir- 
respective of  the  menses.  The  patient  did  not  place  herself  under  medi- 
cal care  until  after  separation  from  her  husband.  Upon  examination  a 
very  sensitive  point  was  found  at  the  anterior  and  inferior  portion  of  the 
vestibule  of  the  vagina,  at  the  level  of  the  remains  of  the  hymen  and  of 
the  adjacent  mucous  membrane.  An  attack  of  epilepsy  could  be  inva- 
riably produced  by  pressing  upon  this  point  and  even  by  touching  it 
lightly  with  nitrate  of  silver;  if  the  examination  were  prolonged  the 
attack  lasted  much  longer.  The  uterus  was  normal  and  insensible  to 
pressure;  there  were  no  symptoms  of  hysteria.  Ferruginous  mineral  waters 
and  local  treatment  proved  ineffectual,  but  the  attacks  of  epilepsy  dis- 
appeared after  the  excision  of  the  sensitive  parts,  and  have  remained 
absent  for  the  past  two  years." 

Disturbances  of  the  digestive  organs  may  also  act  as  causes  of  the 
outbreak  of  the  disease;  thus,  it  has  appeared  after  an  attack  of  subacute 
gastritis,  overloaded  stomach,  and  from  the  presence  of  worms.     But  the 

'  Diseases  of  the  Nervous  System,  1879,  p.  840. 


EPILEPSY.  71 

influence  of  gastro-intestinal  disorders  upon  epilepsy  is  less  evident  and 
frequent  than  that  of  any  other  series  of  reflex  causes. 

Fright,  mental  excitement  or  anxiety,  may  also  act  as  etiological  fac- 
tors. Among  G08  cases  Gowers  found  157  which  were  ascribed  to  these 
causes.  These  cases  were  more  numerous  among  females  than  among 
males,  and  this  is  but  natural,  as  the  former  are  much  more  emotional 
than  the  latter.  A  small  number  of  examples  have  been  reported  in 
which  the  excitement  attendant  upon  seeing  an  individual  during  a  con- 
vulsion has  been  sufficient  to  give  rise  to  an  attack.  In  some  instances, 
cases  which  had  developed  in  this  manner  recurred  spontaneously  after- 
ward. 

The  last  series  of  causes  of  epilepsy  is  composed  of  those  factors  which 
affect  the  general  system.  Foremost  among  these  are  the  infectious  dis- 
eases, although  but  little  mention  is  made  of  them  in  the  various  Vr-orks  on 
this  affection,  except  by 'Gowers,  vvho  reports  nineteen  cases  due  to  scarla- 
tina. Among  my  own  cases  the  infectious  diseases  immediately  preceded 
the  attacks  in  four  cases,  one  of  which  occurred  immediately  after  scarla- 
tina, another  during  the  course  of  scarlatinous  nephritis,  a  third  during 
convalescence  from  typhoid  fever,  and  the  fourth  after  diphtheria.  In  the 
second  case  referred  to,  in  which  the  first  attacks  occurred  during  scarla- 
tinous nephritis,  the  paroxysms  might  perhaps  have  been  regarded  as 
urfemic  in  their  nature,  were  it  not  for  the  fact  that  they  were  attacks  of 
petit  mal,  and  occurred  with  extreme  frequency  (every  day,  and  some- 
times four  or  five  times  a  day).  After  the  disease  had  continued  for 
three  years  attacks  of  grand  mal  occurred. 

We  sometimes,  on  the  contrary,  find  that  an  intercurrent  infectious 
disease,  occurring  during  the  course  of.  epilepsy,  favorably  modifies  the 
progress  of  the  latter.  Thus,  in  a  female  patient  in  whom  the  convul- 
sions had  occurred  with  great  frequency  during  childhood,  the  disease 
disappeared  for  a  period  of  ten  years,  after  passing  through  an  attack  of 
typhoid  fever,  and  only  reappeared  after  the  birth  of  her  second  child, 
while  she  was  worrying  greatly  over  the  bad  habits  of  her  husband. 

Syphilis  sometimes  acts  as  a  cause  of  epilepsy,  the  convulsions  usually 
developing  during  the  tertiary  stage.  In  only  two  cases  under  my  obser- 
vation did  the  attacks  occur  without  being  complicated  by  other  cerebral 
symptoms,  and  in  these  I  am  therefore  inclined  to  believe  that  the  epi- 
lepsy was  due  to  the  direct  action  of  the  syphilitic  virus  upon  the  brain. 
In  the  vast  majority  of  cases,  however,  the  convulsions  of  the  tertiary 
stage  only  constitute  one  of  the  symptoms  of  cerebral  syphilis,  and  we 
shall  again  refer  to  them  in  the  chapter  on  diagnosis. 

Until  very  recently  it  was  supposed  that  syphilitic  epilepsy  only  oc- 
curred during  the  tertiary  period.  Fournier  *  has,  however,  collected 
twelve  cases  (chiefly  in  females)  in  which  the  convulsions  began  during 
the  first  months  of  secondary  syphilis,  and  were  accompanied  by  second- 
ary manifestations  (roseola,  mucous  patches,  etc.).  The  epilepsy  was  re- 
lieved in  all  cases  under  mercurial  treatment.  The  following  case  will 
serve  as  an  illustration: 

"  The  patient,  a  young,  well-nourished  woman,  contracted  syphilis 
three  months  previously.  Upon  admission  to  the  hospital  she  was  found 
to  be  suffering  from  enlargement  of  the  inguinal  glands,  and  had  the  re- 
mains of  the  primary  induration  on  the  labia  majora;  a  papulo-erosive 
syphilide  of  the  vulva  and  general  roseola  were  present.     A  few   days 

'  Annales  de  dermatologie  et  de  syphiligraphie,  1880,  pp.  16 — 24. 


72  FUNCTIONAL    NERVOUS    DISEASES. 

after  her  entrance  into  the  hospital  she  was  suddenly  seized  with  two 
convulsions,  occurring  in  rapid  succession,  after  which  she  remained 
in  a  semi-comatose  condition  until  the  next  morning.  These  two  at- 
tacks were  seen  by  the  interne,  who  stated  that  they  were  typical  epi- 
leptic convulsions.  Upon  the  following  day  the  patient  had  another 
attack,  which  was  witnessed  by  Fournier.  There  was  no  hereditary 
neuropathic  tendency  or  any  other  discoverable  cause  of  epilepsy.  The 
patient  was  put  upon  the  protoiodide  of  mercury  and  rapidly  improved; 
she  was  seen  a  year  later,  but  there  had  been  no  return  of  the  convulsions." 

It  has  also  been  found  in  a  few  cases  that  epilepsy  may  result,  in  chil- 
dren, from  congenital  syphilis. 

Overexertion,  whether  mental  or  physical,  is  also  regarded  as  a  cause. 
I  have  seen  two  examples  of  each  variety.  In  one  of  the  latter  cases  the 
first  convulsion  appeared  after  a  day's  tramp  of  forty  miles  on  the  West- 
ern prairies;  in  the  other,  the  first  attack  came  on  after  the  patient,  a 
girl  of  sixteen,  had  run  a  considerable  distance,  and  was  tired  and  over- 
heated in  consequence. 

In  one  case  the  disease  was  distinctly  traceable  to  excessive  smoking. 
The  patient  was  a  man,  get.  45  years,  in  whom  not  the  slightest  evidences 
of  a  neuropathic  family  history  could  be  discovered.  The  patient  himself 
has,  however,  been  of  a  very  nervous  disposition  since  arriving  at  man- 
hood. He  has  always  been  a  very  steady  smoker,  and  for  six  months 
prior  to  his  first  convulsion,  which  occurred  in  September,  1876,  indulged 
excessively  in  his  favorite  habit,  especially  on  Sundays,  upon  which  day 
he  smoked  continuously  from  morning  until  night.  From  the  occurrence 
of  the  first  fit  until  the  patient  came  under  my  notice  (June,  1878),  he 
had  had  ten  attacks,  all  of  which  occurred  on  Sunday  evenings.  I  placed 
the  patient  on  fifteen-grain  doses  of  bromide  of  potassium,  and  only  per- 
mitted him  to  smoke  three  pipes  daily.  Under  this  treatment  the  fits 
disappeared  until  the  autumn  of  1879,  when  he  had  another  convulsion. 
Upon  inquiry,  however,  I  discovered  that  he  had  discontinued  the  medi- 
cine for  a  month  previously,  and  had,  at  the  same  time,  increased  his  al- 
lowance of  tobacco.  A  renewal  of  the  treatment,  and  a  diminution  in  the 
amount  smoked,  has  again  resulted  in  a  cessation  of  the  attacks  until  the 
present  time  (July,  1880). 


CHAPTER  III. 

PATHOLOGICAL  ANATOMY. 

TnE  pathological  anatomy  of  epilepsy  is  extremely  unsatisfactory,  and 
can  be  disposed  of  in  a  very  short  space  of  time. 

The  most  varied  lesions  have  been  found  affecting  all  parts  of  the 
brain,  not  alone  the  membranes  and  substance  of  the  brain,  but  also  the 
bones  of  the  skull.  The  latter  are  usually  thickened  and  the  dipioe  has 
disappeared,  but,  in  rarer  cases,  the  bones  are  abnormally  thinned.  I 
have  found  these  appearances  in  the  most  varied  forms  of  insanity, 
whether  they  were  complicated  with  epilepsy  or  not.  Sometimes  exos- 
toses are  observed  in  various  parts  of  the  skull,  and  I  have  reported  a 
well-marked  case  of  this  kind  in  the  chapter  on  etiology.  Considerable 
stress  has  been  laid  on  stenosis  of  the  foramen  magnum,  as  this  anomaly 
has  been  observed  in  quite  a  number  of  cases. 

Lasegue  '  has  recently  claimed  that  epilepsy  is  due  to  a  malformation 
or  vice  of  consolidation  of  the  bones  which  form  the  base  of  the  skull. 
According  to  him,  this  malformation  is  indicated  by  the  following  char- 
acteristic  appearances  :  the  frontal  protuberance  is  usually  much  more 
marked  on  the  right  side  than  on  the  left  ;  there  is  a  corresponding  pro- 
jection of  the  malar  bone  ;  the  face  is  rotated,  the  osseous  line  of  the 
palate  deviates  from  the  median  line  of  the  body  ;  deformity  of  the  arch 
of  the  palate  ;  lowering  or  raising  of  one  of  the  orbits  ;  one  side  of  the 
face  is  sunken,  corresponding  to  the  projection  of  the  other.  In  confir- 
mation of  his  views,  Lasegue  states  that  epilepsy  usually  begins  from  the 
twelfth  to  the  eighteenth  years,  a  period  which  corresponds  to  that  of  the 
consolidation  of  the  bones  of  the  base  of  the  skull. 

Garel,*  who  also  investigated  this  topic,  found  fifty-two  cases  of  facial 
asymmetry  among  ninety-four  epileptics,  or  SSyVo  P^r  cent.  Among 
ninety-four  cases  of  non-epileptics  taken  indiscriminately,  he  found 
thirty-eight  cases  of  facial  asymmetry,  or  40y\2„-  per  cent.  The  difference 
between  epileptics  and  non-epileptics  in  this  respect  is,  therefore,  too 
small  to  entitle  the  as3'mmetry  to  be  looked  upon  as  a  cause  of  the  disease. 

The  cerebral  meninges  sometimes  present  the  evidences  of  chronic 
meningitis,  and  at  times  they  are  entirely  normal.  I  have  found  inflamma- 
tion of  the  dura  mater  (pachymeningitis)  in  several  insane  epileptics,  and 
in  one  of  them,  who  died  in  the  status  epilepticus,  the  membrane  on  the 
dura  mater  was  sufficiently  thick  to  produce  compression  of  the  frontal 
and  parietal  lobes  on  the  right  side  of  the  brain.  I  have,  however, 
found  similar  pachymeningitic  exudations  in  other  insane  patients  who 
had  never  suffered  from  epilepsy,  as  well  as  in  sane  individuals  who  have 
had  the  most  various  diseases. 

The  examinations  of  the  structure  of  the  brain  itself  has  likewise  led 

1  Bulletin  de  I'Acad.  de  Mcdecine,  1877. 
'  Lyon  Medical,  Jan.  6,  1878. 


74  rUNCTIONAL   NERVOUS    DISEASES. 

to  various  results.  In  perhaps  the  majority  of  cases  no  abnormal  appear- 
ances have  been  observed.  Schroeder  van  der  Kolk,'  to  whose  researches 
great  importance  has  been  attached,  sums  up  the  results  of  his  investiga- 
tions as  follows  : 

"In  the  commencement  of  epilepsy  it  would  seem  that  no  apparent 
organic  change  exists.  Rapidly,  however,  probably  in  consequence  of 
the  repeated  congestion,  the  presence  of  a  more  albuminous  cellular  fluid 
between  the  nervous  filaments  is  manifested,  which  may  first  cause  more 
or  less  hardening,  and  may  subsequently  give  rise  to  fatty  degeneration 
and  softening.  In  addition,  dilatation  of  the  arterial  capillaries  and 
thickening  of  their  walls  ensue." 

"  These  blood-vessels  in  the  medulla  oblongata  run  chiefly  in  the  region 
of  the  roots  of  the  hypoglossus  and  vagus,  as  well  as  in  the  septum  and 
corpora  olivaria.  The  posterior  half  of  the  medulla  oblongata  from  the 
fourth  ventricle,  in  epileptic  subjects,  appears,  on  a  transverse  section, 
redder  and  more  hyperaemic  than  in  the  normal  state,  whether  the  suffer- 
ers died  during  an  attack  or  not." 

"  In  epileptics  who  bite  the  tongue  during  the  fit,  the  capillary  ves- 
sels are  usually  wider  in  the  course  of  the  hypoglossus  and  corpora  oliva- 
ria ;  in  those  who  do  not  bite  the  tongue  they  are  wider  in  the  course  of 
the  vagus." 

Echeverria  substantiated  the  results  of  Van  der  Kolk's  investigations, 
and,  in  addition,  found  even  more  advanced  lesions.  In  the  medulla 
oblongata,  he  observed  granular  cells,  an  increase  in  the  number  of  amy- 
loid bodies,  and  pigmentation  of  the  ganglion  cells,  especially  in  the  nu- 
clei of  the  hypoglossal  and  pneumo.gastric  nerves  ;  hyperplasia  of  the 
connective  tissue  was  also  noticeable.  He  also  observed  similar  lesions 
in  various  portions  of  the  convolutions  of  the  brain,  but  while  they  were 
sometimes  absent  in  these  localities,  they  were  invariably  present  in  the 
medulla. 

Echeverria  also  found  the  following  changes  in  the  cervical  sympa- 
thetic, which  he  considers  characteristic  of  the  disease  :  the  ganglion 
cells  were  broken  up,  shrunken,  or  infiltrated  with  brownish  colored  gran- 
ules, which  concealed  the  nuclei.'  The  cells  were  atrophied  from  the 
pressure  caused  by  the  increase  of  slender,  nucleated,  transparent  fibres, 
fatty  graniales,  and  amyloid  corpuscles.  Many  of  the  nerve-fibres  had 
lost  their  contents,  so  that  nothing  was  left  but  the  sheaths  ;  in  others 
the  fibres  had  become  granular  ;  the  tubes,  which  were  destitute  of  axis 
cylinders,  contained  numerous  oval  nuclei. 

Ludwig  Mayer,  who  made  careful  investigations  "with  regard  to  these 
points,  has  found  all  these  changes  in  other  cerebral  diseases,  and  regards 
them  as  secondary  to  the  frequent  recurrence  of  circulatory  disturbances. 
I  have  made  no  investigations  with  regard  to  the  occurrence  of  such 
changes  in  the  medulla,  but  I  may  state  that  I  have  frequently  found 
these  lesions  in  different  parts  of  the  cerebral  convolutions  in  various 
forms  of  insanity,  and  have  always  regarded  them  in  such  cases  as  second- 
ary to  chronic  cerebral  congestion. 

It  is  very  evident,  therefore,  that  these  lesions  are  not  the  causes, 
but  rather  the  effects  of  epilepsy. 

'  On  the  Minute  Structure  and  Functions  of  the  Spinal  Cord  and  Medulla  Oblongata, 
and  On  the  Proximate  Cause  and  Rational  Treatment  of  Epilepsy,  1859. 

'  Labiraoff  states  that  pigmentation  of  the  ganglion  cells  is  habitually  found  in  older 
people,  and  is  not  infrequent  even  in  the  young. 


EPILEPSY.  75 

Epilepsy  may  also  be  secondary  to  any  localized  aiTections  in  the  brain, 
such  as  tumors  of  the  meninges  or  brain  tissue,  hemorrhages,  softening 
from  various  causes,  abscesses,  cysts,  etc.  Tumors  of  the  dura  mater  and 
cortex  play  an  important  part  in  this  connection. 

There  is  no  doubt,  therefore,  from  this  brief  resume  of  the  results  of 
the  anatomical  investigations  with  regard  to  this  disease,  that  there  is  no 
pathological  anatomy  of  epilepsy.  All  the  numerous  changes  which  have 
been  observed  are  either  secondary  lesions  or  they  shed  no  light  upon  the 
real  cause  of  the  affection.  We  are  also  inclined  to  believe  tiiat  the  path- 
ological anatomy  of  the  future  will  not  add  much  to  our  knowledge,  or 
rather,  will  not  dispel  our  ignorance  concerning  the  disease.  It  appears 
to  us,  in  view  of  the  perfection  to  which  modern  histological  methods 
have  arrived,  and  of  the  numerous  and  careful  investigations  which  have 
been  made  by  enthusiastic  observers,  that  some  positive  results  should 
have  been  reached,  if  they  are  within  the  range  of  possibility.  Perhaps 
it  will  be  left  for  the  physiological  chemist,  to  whose  domain  so  many 
other  pathological  questions  will  be  relegated,  to  discover  the  true  essence 
of  the  disease.  But  our  ignorance  on  this  point  should  not  daunt  us  in 
the  search  of  a  curative  remedy.  Our  art  pre-eminently  is  or  should  be 
a  healing  one,  and  it  is  far  better  to  grope  blindly  and  empirically  for 
better  therapeutic  agents,  than  it  is  to  fold  our  arms  in  despair  until  the 
anatomist  has  informed  us  what  the  lesion  really  is. 

Pathology . — Numerous  experimental  investigations  have  been  made 
in  order  to  shed  some  light  upon  the  pathology  of  epilepsy,  but  opinions 
are  still  at  variance  on  this  point.  Some  authorities  locate  the  primary 
lesion  in  the  convolutions  of  the  brain,  others  in  the  pons  and  medulla. 

Kussmaul  and  Tenner  first  showed,  by  experiments  on  the  lower  ani- 
mals, that  anosmia  of  the  brain  will  give  rise  to  loss  of  consciousness  and 
general  convulsions  (at  first  tonic,  then  clonic).  They  concluded,  from 
their  experiments,  that  the  primary  disturbance  was  situated  in  the 
medulla  oblongata  (which  is  now  known  to  be  the  site  of  the  vaso-motor 
centre),  and  that  irritation  of  the  medulla  gave  rise  to  spasm  of  the  cere- 
bral vessels,  anaemia  of  the  organ,  and  consequently  produced  loss  of  con- 
sciousness and  convulsions.  From  the  result  of  his  anatomical  investiga- 
tions, Schroeder  van  der  Kolk  was  also  led  to  look  upon  the  medulla  ob- 
longata as  the  site  of  the  disease. 

Brown-Sequard  has  made  numerous  experiments  on  the  artificial  pro- 
duction of  epilepsy  in  animals,  especially  in  guinea-pigs.  He  showed 
that  the  disease  develops  in  these  animals  after  various  injuries  to  the 
nervous  system,  such  as  division  of  peripheral  nerves,  incision  of  the  col- 
umns of  the  spinal  cord,  etc.  AVithin  a  month  to  a  month  and  a  half  after 
the  experiment,  the  first  attack  of  epilepsy  usually  develops.  After  this 
they  may  occur  spontaneously  or  upon  irritation  of  the  so-called  epilepto- 
genic zone,  which  includes  the  cheek  and  anterior  portion  of  the  neck. 
Brown-Sequard  also  made  the  curious  observation  that  the  young  of  guinea- 
pigs,  who  have  been  made  epileptic  in  this  manner,  may  develop  the  dis- 
ease spontaneously.  These  experiments  have  been  repeatedly  verified  by 
Schiff,  Westphal,  and  numerous  other  observers.  Westphal  also  showed 
that  similar  results  may  be  obtained  by  striking  the  animals  gently  upon 
the  head;  in  these  cases,  he  found  small  hemorrhagic  extravasations  in 
the  medulla  oblongata  and  upper  portion  of  the  cervical  cord. 

Still  later,  Nothnagel '  showed  that  the  "  convulsive  centre  "  for  the 

•  Virchow's  Archiv.  Bd.  XLIY. 


76  FUNCTIONAL    NERVOUS    DISEASES. 

muscles  of  the  entire  body  is  situated  in  the  pons  varolii.  The  theory 
mentioned  above  was  then  modified  in  view  of  the  results  of  Nothnagel's 
investigations.  This  author  believes  that  "  the  irritation  of  the  vaso- 
motor centre  and  of  the  centre  for  the  muscles  (convulsive  centre)  is  co- 
ordinate," and  that  one  of  these  parts  may  alone  be  irritated.  In  this 
manner  he  explains  the  variations  in  the  character  of  the  epileptic  seizures. 
Thus,  irritation  of  the  convulsive  centre  alone  would  give  rise  to  convul- 
sions unattended  by  loss  of  consciousness  (as  in  the  case  mentioned  on 
page  49),  while  irritation  of  the  vaso-motor  centre  would  produce  loss  of 
consciousness  or  psychical  disturbances,  according  as  the  secondary  cere- 
bral anaemia  affects  the  entire  convolutions  or  only  certain  portions. 

This  view  presupposes  an  abnormal  irritability  (in  many  cases  of  a 
congenital  nature)  of  the  pons  and  medulla. 

The  English  school  of  investigators,  following  the  lead  of  J.  Hugh- 
lings  Jackson,  have  formulated  a  different  hypothesis.  Jackson,  in  an 
article  published  in  the  "  West  Riding  Reports  for  1873,"  states  that  "  de- 
fined from  the  paroxysm,  epilepsy  is  a  sudden,  excessive,  and  rapid  dis- 
charge of  gray  matter  of  some  ^:»a?*^  of  the  brain;  it  is  a  local  discharge. 
To  define  it  from  the  functional  alteration,  we  say  there  is  in  a  case  of 
epilepsy  gray  matter  which  is  so  abnormally  nourished  that  it  occasionally 
reaches  very  high  tension,  and  therefore  occasionally  '  explodes.'  The  two 
definitions  are  different  faces  of  the  same  thing."  Since  the  publication 
of  this  article,  Jackson  '  advanced  the  opinion  that  the  cells  of  the  brain 
suffer  secondarily  in  epilepsy  as  a  consequence  of  arterial  disease,  and  that 
there  is  thrombosis  or  embolism  of  small  arteries  in  most  cases. 

According  to  this  theory,  the  nerve-cells  are  in  a  condition  of  unstable 
equilibrium  (attributed  by  some  to  excessive,  by  others  to  deficient  nutri- 
tion), and  the  phenomena  of  epilepsy  are  due  to  the  sudden  and  violent 
action  of  these  cells,  i.  e.,  to  the  sudden  liberation  of  nerve-force. 

The  various  modifications  in  the  phenomena  observed  during  a 
paroxysm  are  supposed  to  be  due  to  the  location  of  the  nerve-cells  which 
are  thus  affected. 

Probably  the  strongest  argument  in  favor  of  the  theory  that  the  "  dis- 
charge "  begins  in  the  convolutions  is  found  in  the  fact  that  so  many 
epileptics  present  a  special  sense  or  even  intellectual  aura,  which  could 
not  have  been  produced  by  any  functional  disturbance  of  the  pons  varolii 
or  medulla,  but  must  be  attributed  to  a  "  discharge  "  of  the  higher  cen- 
tres, viz.,  the  convolutions. 

Gowers  claims  that  the  hypothesis  of  vaso-motor  spasm  is  unneces- 
sary, as  all  the  phenomena  can  be  explained  by  the  discharge  of  gray 
matter. 

There  is  no  doubt  that  all  the  symptoms  of  epilepsy  may  be  inter- 
preted in  the  light  of  Jackson's  theory,  but  his  views  are,  after  ail,  mere 
matters  of  speculation,  and  we  shall,  therefore,  forbear  from  their  further 
consideration. 


'  Lancet,  Jan.  35,  1879. 


CHAPTER  lY. 

'  DIAGNOSIS  AND  PROGNOSIS. 

In  chronic  cases  of  grand  mal,  in  which  there  is  a  history  of  repeated 
typical  epileptic  convulsions,  occurring-  spontaneously  and  not  accom- 
panied by  any  other  cerebral  symptoms,  the  diagnosis  is  evident  at  the 
first  glance.  But  mistakes  are  readily  made,  even  in  cases  of  grand  mal, 
when  the  convulsions  occur  only  at  night.  Nocturnal  incontinence  of 
urine  in  the  adult  should  always  arouse  our  suspicions  in  this  direction. 
If,  in  addition,  the  patient  complains  of  being  worn  out  in  the  morning 
and  feeling  "as  if  he  had  been  working  all  night,"  if  the  tongue  feels 
sore  and  the  pillow  is  stained  with  a  little  blood,  or  if  a  petechial  erup- 
tion is  found  in  various  portions  of  the  face,  especially  around  the  outer 
angles  of  the  eyes — when  all  these  symptoms  are  combined,  the  testi- 
mony in  favor  of  nocturnal  epilepsy  is  very  strong  indeed.  In  cases  of 
this  nature,  we  should  always  direct  the  patient  to  sleep  with  a  com- 
panion, so  that  we  may  obtain  positive  evidence  of  the  existence  of  the 
disease.  In  exceptional  cases  of  this  kind  we  may  thus  be  able  to  deter- 
mine the  presence  of  epilepsy  in  individuals  in  whom  it  had  not  been 
suspected. 

If  a  patient  gives  a  history  that  he  has  suffered  some  contusion  or 
injury  during  his  sleep  and  was  entirely  unaware  of  any  accident,  careful 
examination  should  also  be  made.  Trousseau  mentions  a  case  in  which 
dislocation  at  the  shoulder-joint  occurred  twice  at  night,  the  patient 
being  ignorant  of  the  accident  until  he  awoke  in  the  morning.  Basing 
his  opinion  on  these  facts,  Trousseau  made  a  diagnosis  of  nocturnal  epil- 
epsy, and  other  details  which  were  then  communicated  by  the  patient 
dissipated  all  further  doubt. 

Sometimes  we  are  called  upon  to  differentiate  real  from  feigned  epi- 
lepsy. When  the  malingerer  is  intelligent  and  has  closely  observed  the 
disease,  it  may  be  very  difficult  to  detect  the  simulation.  Thus  Trousseau 
relates,  in  his  lecture  on  epilepsy,  that  Calmeil  simulated  an  epileptic 
convulsion  so  perfectly  in  Esquirol's  presence,  that  the  latter  thought  the 
attack  was  real.  Dr.  Gorton,  of  the  State  Asylum  for  Insane  Criminals, 
informed  me  that  he  had  under  his  care  a  thief  who  feigned  epilepsy  so 
well  that  a  number  of  London  hospital  physicians  were  deceived.  As  a 
rule,  however,  the  deception  is  readily  detected  with  a  little  care.  An 
individual  feigning  epilepsy  usually  finds  a  soft  spot  to  fall  upon,  pallor 
of  the  face  does  not  develop,  the  pupils  are  not  dilated,  the  reflexes  are 
preserved,  the  face  does  not  become  so  dusky  during  the  clonic  stage, 
and  the  attack  is  not  followed  by  coma  ;  general  sensation  is  well  pre- 
served, and  the  patient  reacts  upon  a  sufficiently  powerful  stimulus. 
Yoisin  regarded  the  changes  in  the  sphygmographic  tracings  of  the 
pulse  during  an  attack  as  pathognomonic,  but  further  investigations  have 
disproved    this    statement.       In    determining   whether    a   convulsion    is 


At 


78  FUNCTIONAL   NERVOUS   DISEASES. 

feio-ned  or  real,  we  should  be  guided  by  tlie  tout  ensemble  of  the  symp- 
toms, and  not  by  the  presence  or  absence  of  a  single  one.  A  great  deal 
•will  depend  upon  the  quickness  of  observation  and  the  judgment  of  the 
physician. 

The  diagnosis  of  petit  mal  is  much  more  difficult  than  that  of  the 
grand  or  haut  mal.  When  the  two  forms  are  combined,  petit  mal  is 
readily  recognized  on  account  of  its  combination  with  well-marked  con- 
vulsive seizures.  But  when  the  former  variety  alone  occurs,  its  true  sig- 
nificance is  frequently  overlooked,  and  it  is  often  mistaken  for  simple 
svncope  or  vertigo.  Petit  mal  is  often  preceded  by  an  aura,  and  this 
should  always  be  inquired  into  very  carefully,  as  it  is  a  very  important 
sio-n.  Furthermore,  the  attack  may  occur  in  a  patient  who  is  otherwise 
in  perfect  health,  and  in  whom  no  cause  for  syncope  can  be  discovered  ; 
the  former  is  also  often  accompanied  by  inarticulate  muttering,  and,  if 
the  individual  is  closely  watched,  slight  convulsive  twitchings  may  be  no- 
ticed in  the  face  or  hands. 

The  sufferer  from  petit  mal  is  usually  unconscious  of  the  occurrence  of 
the  "  weak  spell"  and,  if  not  told  by  those  around  him,  might  have  a  con- 
siderable number  of  attacks  without  becoming  aware  of  it.  Upon  close 
inquir}',  we  may  discover  that  the  patient's  memory  is  failing,  that  his  in- 
tellectual powers  are  not  up  to  their  normal  condition,  and  perhaps  that 
another  member  of  the  family  has  suffered  from  epilepsy  or  some  other 
severe  neurosis. 

Quite  a  large  number  of  cases  have  come  under  my  observation  in 
which  this  affection  had  been  entirely  overlooked,  and  we  are  convinced 
that  the  profession  is  not  by  any  means  fully  alive  to  the  frequency  or 
gravity  of  this  form  of  epilepsy.  The  following  case  will  show  how 
readily  the  nature  of  the  disease  may  be  misconstrued,  as  it  was  only 
by  a  mere  accident  that  I  was  led  to  recognize  its  true  character. 

A  young  woman,  fet.  22  years,  consulted  me  with  reference  to  an 
angina  pectoris  which  had  lasted  for  four  years.  She  complained  of 
attacks,  occurring  at  irregular  intervals,  during  which  she  had  severe 
shooting  pains  in  the  prjecordial  region,  radiating  thence  into  the  left 
arm;  this  was  accompanied  by  dyspnoea,  great  dread,  and  a  feeling  as 
if  the  heart  had  stopped  beating.  At  the  termination  of  these  symptoms, 
which  only  lasted  a  couple  of  seconds,  the  patient  would  faint  away. 
Upon  obtaining  this  history,  I  made  a  careful  physical  examination  of  the 
heart,  but  the  results  were  entirely  negative.  I  then  questioned  the  patient 
with  regard  to  the  condition  of  the  uterus,  thinking  that  the  angina  was 
perhaps  the  reflex  result  of  irritation  of  that  organ.  She  gave  a  history 
of  profuse  leucorrhoea,  menorrhagia,  and  severe  pain  in  the  back,  I  then 
proceeded  to  make  a  vaginal  examination,  but  my  finger  had  no  sooner  come 
in  contact  with  the  os  uteri,  than  the  patient  became  perfectly  rigid,  and 
did  not  answer  me  when  addressed.  Upon  touching  the  cornea  no  re- 
sponse was  elicited,  the  respirations  ceased,  the  pulse  remained  normal; 
the  color  of  the  face  did  not  change.  After  a  period  which  appeared  to 
me  about  a  minute,  the  patient  recovered  consciousness  but  was  bewil- 
dered for  a  short  time.  The  character  of  the  disease  Avas  now  evident. 
The  fainting  spells  Avere  true  attacks  of  petit  mal,  and  the  symptoms  of 
angina  pectoris  merely  constituted  an  aura.  Upon  questioning  the  patient 
more  carefully,  I  then  discovered  that  she  frequently  had  fainting  spells 
without  any  previous  anginal  seizures,  and  that  she  would  fall  wherever 
she  happened  to  be;  I  also  learned  that  her  memory  had  failed  con- 
siderably.    The  only  cause  to  which  I  could  attribute  the  disease  was 


EPILEPSY.  79 

mental  distress  arising'  from  the  ill-treatment  of  herself  and  mother  by  her 
step-father. 

The  recognition  of  the  variety  of  peculiar  attacks  which  we  have  de- 
scribed under  the  heading  of  irregular  epilepsy  is  often  extremely  difficult. 
Their  distinguishing  feature  consists  in  the  fact  that  they  usually  occur 
in  patients  who  are  also  affected  either  with  grand  or  petit  mal,  and  the 
occurrence  of  any  group  of  symptoms  appearing  in  paroxysms  should 
always  arouse  our  suspicions  under  such  circumstances.  But,  as  we  have 
previously  stated,  the  usual  forms  of  the  disease  may  never  have  occurred. 
Important  characteristics  of  these  seizures  consist  in  the  fact  that  they 
occur  suddenly  and  spontaneously  in  paroxysms  of  variable  duration; 
that  an  aura  may  be  present,  that  consciousness  is  either  entirely  lost  or 
at  least  disordered,  and  that  no  symptoms  are  noticeable  during  the  in- 
tervals between  the  attacks. 

We  should  always  examine  carefully  into  the  presence  of  any  neuropathic 
family  history  or  of  an}'  of  the  predisposing  or  exciting  causes  of  epilepsy. 
Whether  or  no  the  symptoms  described  by  Griesinger  as  epileptoid  condi- 
tions, should  be  included  under  this  head  will  depend  in  great  measure  upon 
the  individual  bias  of  the  observer.  Their  epileptic  character  is  rendered 
more  probable  if  the  patient  has  previously  suffered  from  well-marked  con- 
vulsive seizures.  This  must  be  especially  taken  into  consideration  before 
making  a  diagnosis  of  epileptic  sweating,  such  as  we  have  referred  to  on 
page  57,  since  very  similar  attacks  frequently  occur  during  what  we  have 
termed  the  menopause  neurosis,  and  evidently  stand  in  no  relation  to 
epilepsy 

We  are  frequently  called  upon  to  distinguish  epilepsy  from  eclampsia 
infantum.  There  is  nothing  in  the  symptomatology  of  the  convulsions 
which  will  serve  to  differentiate  the  two  diseases.  The  convulsions  of 
epilepsy,  however,  recur  at  longer  or  shorter  intervals,  usually  without 
any  exciting  cause,  after  the  disease  has  become  developed,  and,  as  a  rule, 
only  one  convulsion  occurs  at  a  time.  It  is  also  important  to  enter  care- 
fully into  the  family  history  in  order  to  determine  whether  any  hereditary 
neuropathic  tendency  is  manifested.  Eclampsia  infantum  follows  some 
definite  exciting  cause,  such  as  dentition,  intestinal  worms,  gastric  irritation, 
or  the  onset  of  an  acute  disease.  Very  frequently,  also,  the  little  patient 
suffers  from  a  series  of  convulsions,  which  follow  one  another  in  rapid 
succession,  and  which  may  last  for  hours  with  hardly  any  intermission. 
In  not  a  few  cases,  however,  it  will  be  impossible  to  make  a  differential 
diagnosis  for  a  very  long  time,  and  in  some  instances  this  difficulty  is 
obviated  by  saying  that  eclampsia  infantum,  if  frequently  repeated,  may 
become  converted  into  true  epilepsy. 

Difficulty  is  sometimes  experienced  in  distinguishing  the  uraemic  con- 
vulsions of  cirrhosis  of  the  kidneys  from  true  epilepsy.  The  urtemic 
convulsions  may  occur  suddenly  in  a  patient  who  has  apparently  enjoyed 
perfect  health,  and  indeed  several  series  of  attacks  may  be  repeated  at 
variable  periods,  although  the  patient  appears  to  be  well  during  the  in- 
tervals. There  are  several  symptoms,  however,  presented  by  patients 
suffering  from  granular  kidneys,  which  are  very  characteristic  and  enable 
us,  with  a  little  care,  to  make  a  correct  diagnosis.  In  the  first  place, 
various  grades  of  hypertrophy  of  the  left  ventricle  are  present  in  all 
cases;  this  usually  produces  no  symptoms  and  is  unnoticed  by  the  patient. 
The  tension  of  the  arteries  throughout  the  body  is  greater  than  normal,  and 
is  shown  by  increased  resistance  of  the  radial  pulse.  The  urine  is  increased 
in  quantity  and  diminished  in  specific  gravity.     There  may  be  a  slight 


80  FUNCTIONAL   NERVOUS    DISEASES. 

amount  of  albumen  present,  or  the  urine  may  be  entirely  free  from  it  ;  a 
few  hyaline  casts  are  observed  from  time  to  time.  The  character  of  the 
convulsion  also  differs  somewhat  from  that  of  epilepsy.  It  is  usually  very 
violent,  is  never  preceded  by  an  aura,  and  the  subsequent  coma  may  be 
very  profound  and  even  give  rise  to  serious  alarm.  Furthermore,  we  not 
unfrequently  find  that  the  convulsions  occur  in  series,  during  which  cere- 
bral hemorrhage  may  be  produced. 

Hysterical  convulsions  are  usually  distinguished  with  readiness  from 
those  occurring  in  epilepsy.  The  former  generally  occur  in  young  fe- 
males, who  also  present  other  well-marked  symptoms  of  hysteria;  con- 
sciousness is  not  lost  during  the  attack,  but  is,  at  most,  slightly  disordered; 
the  convulsive  movements  do  not  present  the  same  regularity  observed  in 
an  epileptic  seizure;  the  patient  throws  herself  into  peculiar  positions,  rolls 
around  from  one  place  to  another;  respiration  is  not  so  completely  inter- 
rupted, and  the  entire  attack  may  last  from  several  minutes  to  an  hour 
or  more. 

Hysterical  convulsions  may  be  very  frequently  repeated,  but  coma 
does  not  often  develop  after  these  attacks.  Bourneville  has  shown  that 
a  rapid  succession  of  hysterical  seizures  may  be  readily  diagnosticated 
from  the  status  epilepticus  (vide  page  51),  by  the  fact  that  the  latter  is 
attended  by  a  rapid  rise  of  temperature,  while  the  former  is  never  accom- 
panied by  this  symptom.*  Finally,  hysterical  convulsions  may  often  be 
arrested  by  measures  which  are  directed  toward  the  imagination  of  the 
patients.  We  must  not  forget,  however,  that  epilepsy  and  hysteria  are 
frequently  combined  in  the  same  patient,  especially  among  the  inmates  of 
an  hospital  for  epileptics. 

The  epileptic  seizures  which  occur  as  a  symptom  of  cerebral  syphilis 
(gummata,  vessel  changes,  etc.),  should  also  be  distinguished  from  idio- 
pathic epilepsy.  In  the  former  disease,  the  patient  generally  gives  a 
history  of  previous  infection  with  the  syphilitic  virus,  and  other  manifes- 
tations of  the  cerebral  disorder  are  presented  prior  to  the  development 
of  the  epilepsy.  Prominent  among  these  symptoms  is  intense  headache, 
which  always  grows  much  worse  at  night;  ptosis,  pupillary  disturbances, 
or  paresis  of  various  portions  of  the  body  make  their  appearance  ;  optic 
neuritis  is  often  present.  When  convulsions  occur,  any  paresis  which  may 
have  been  present  is  usually  deepened  into  paralysis,  and  this  may  par- 
tially disappear  after  a  variable  period.  Not  infrequently  the  convulsions 
are  at  first  unilateral,  and  we  have  sometimes  seen  them  confined  to  one 
limb.  Unless  active  treatment  is  instituted,  however,  the  convulsions 
soon  become  general,  and  then  differ  in  no  respect  from  those  of  ordinary 
epilepsy.  One  of  the  most  characteristic  features  of  this  disease  is  its 
curability  under  anti-syphilitic  remedies,  though,  unless  treatment  is  be- 
gun soon  after  the  first  cerebral  symptoms  have  presented  themselves, 
there  is  great  danger  of  a  relapse.  It  is  also  important  to  remember 
that  these  manifestations  of  syphilis  generally  make  their  appearance 
after  the  age  of  thirty,  so  that  this  fact  should  always  put  us  on  our 
guard. 

Epilepsy  offers,  on  the  whole,  a  very  gloomy  prognosis,  and  some  phy- 
sicians have  even  gone  so  far  as  to  deny  its  curability  in  any  case.  This- 
is,  however,  not  true,  as  a  very  small  percentage  of  cases  appear  to  re- 
cover spontaneously. 

'  As  previously  mentioned,  I  have  observed  a  case  of  status  epilepticus  in  which 
no  rise  of  temperature  occurred. 


EPILEPSY.  81 

It  must  be  remembered  that  the  convulsions  may  run  a  very  irregular 
course,  and  a  case  should,  therefore,  not  be  regarded  as  permanently  cured 
unless  at  least  three  years  have  elapsed  since  an  epileptic  seizure  has  oc- 
curred. 

In  a  considerable  number,  perhaps  a  majority,  of  the  cases,  the  fre- 
quency and  severity  of  the  fits  may  be  very  materially  diminislied,  and  in  a 
few  they  will  entirely  disappear.  The  chances  of  recovery  increase  ac- 
cording as  the  disease  is  due  to  some  definite,  removable  cause,  as  in  cer- 
tain cases  of  reflex  epilepsy.  The  duration  of  the  disease  prior  to  begin- 
ning treatment  is  also  of  importance,  the  chances  of  recovery  being 
greater  the  earlier  the  affection  is  recognized  and  treated;  it  is  generally 
supposed  that,  if  the  patient  has  already  had  100  convulsions  before  the 
treatment  is  begun,  the  prognosis  is  very  poor;  if  as  many  as  500  have 
occurred,  there  is  not  the  slightest  chance  of  recovery. 

The  prognosis  is  somewhat  better  when  the  disease  begins  early  in 
life,  than  if  it  develops  during  manhood.  An  hereditary  influence  decid- 
edly lessens  the  patient's  chances,  and  cases  of  this  kind  are  also  more 
liable  to  become  complicated  with  mental  disorders.  It  is  still  undecided 
whether  the  grand  or  petit  mal  is  the  more  curable.  Judging  from  my 
own  experience,  I  am  inclined  to  believe  that  the  latter  form  is  more  sus- 
ceptible of  improvement  than  the  former.  I  have  also  begun  to  entertain 
considerable  doubt  in  the  general  belief  that  petit  mal  is  more  apt  to  be 
attended  with  psychical  disorders  than  the  grand  mal. 

Those  patients  in  -whom  epileptic  mania  has  developed  usually  go  from 
bad  to  worse,  and  generally  terminate  eventually  in  dementia.  Never- 
theless, I  have  seen  several  cases  in  the  young  in  whom  a  return  to  a  nor- 
mal condition  of  intellect  was  effected,  although  the  patients  had  suffered 
from  considerable  mental  disturbance. 

The  prognosis  as  regards  life  is  excellent,  and  death  only  occurs  in  ex- 
ceptional cases  from  an  accident  during  the  convulsion,  such  as  suffoca- 
tion, drowning,  fracture  of  the  skull,  cerebral  hemorrhage,  etc.  When 
the  status  epilepticus  develops,  however,  a  fatal  termination  is  not  infre- 
quent either  in  the  convulsive  or  meningitic  stage.  But  these  cases  are 
comparatively  rare. 

In  some  cases,  an  example  of  which  is  shown  in  the  following  history, 
a  fatal  result  follows,  although  the  cause  of  death  remains  unknown  or  is 
very  obscure: 

Case  XIII. — Anne  C,  vet.  26  years,  single,  no  hereditary  taint  discover- 
able. The  patient  was  always  of  a  nervous  temperament,  but  in  tolerably 
fair  health,  until  five  years  ago.  At  that  time  she  obtained  extremely 
little  sleep  for  a  period  of  five  months  (was  acting  as  a  nurse).  The  first 
epileptic  paroxvsm  developed  shortly  afterward,  and  was  of  the  nature  of 
grand  mal.  The  attacks  then  made  their  appearance  with  continually  in- 
creasing frequency,  the  memory  began  to  be  impaired,  and,  finally,  the 
patient  became  very  forgetful.  When  she  first  came  under  my  observa- 
tion, a  marked  hysterical  condition  was  manifest.  The  treatment  con- 
sisted of  the  administration  of  bromide  of  potassium,  gr.  xv.  t.i.d.  As 
the  patient  was  unable  to  find  employment  on  account  of  her  condition,  I 
admitted  her  to  my  wards  in  Randall's  Island  Hospital,  February  14, 1880, 
and  the  dose  of  bromide  was  then  increased  to  gr.  xxx.  t.i.d.  Soon  after 
admission,  the  hysterical  symptoms  became  aggravated,  and  the  patient 
(who  was  a  Protestant)  began  to  suffer  from  the  delusion  that  the  nurse 
and  the  Catholic  patients  in  the  ward  were  abusing  and  persecuting  her. 
6 


82  FUNCTIONAL    NERVOUS    DISEASES. 

At  intervals  she  refused  food,  stating  that  an  attempt  was  being  made 
to  poison  her.  On  several  occasions  she  attempted  to  run  out  of  the  hos- 
pital in  her  night-gown,  and  sometimes  used  violence  toward  the  other  pa- 
tients. She  gradually  became  more  morose  and  listless  and  finally  took  to 
bed  (March  20th).  After  this  she  lay  in  a  stupid  condition,  interrupted  on 
one  occasion  by  an  attack  of  excitement,  during  which  she  attempted  to 
get  out  of  bed,  and  struck  an  attendant.  She  then  refused  food  during 
an  entire  week  (for  fear  of  being  poisoned),  and  was  fed  by  means  of 
rectal  enemata.     The  patient  gradually  sank  and  died  April  8,  1880. 

Autopsy — held  by  the  curator,  Dr.  Habirshaw.  Brain. — On  the  in- 
ferior portion  of  the  right  occipital  lobe  was  a  small  patch  of  enlarged 
vessels,  presenting  the  appearance  of  minute  hemorrhages.  The  pia 
mater  was  slightly  roughened  over  the  vertex  and  adherent  in  some 
places;  the  interior  of  the  brain,  including  the  ganglia,  was  congested. 
Lungs. — The  lower  lobes  of  both  lungs  contained  a  few  lobules  of  catar- 
rhal pneumonia  of  various  sizes,  attended  with  hypostatic  congestion; 
some  of  the  bronchi  contained  thick  pus. 

Neither  the  morbid  appearances  in  the  brain  or  lungs  were  sufficient 
to  account  for  the  symptoms.  Another  case  of  a  very  similar  nature,  and 
also  attended  with  a  fatal  result,  has  come  under  my  observation.  In  this 
instance  I  was  unable  to  obtain  an  autopsy. 


CHAPTER   V. 

TREATMENT. 

Many  authorities  regard  the  disease  as  entirely  incurable,  and  do  not 
even  attempt  to  treat  it,  while  others  have  recorded  a  large  proportion 
of  successes.  In  our  opinion,  the  truth  lies  midway  between  these  two 
extremes. 

One  of  the  most  important  points  to  be  remembered  is  that  every 
case  must  be  treated  by  itself;  that  we  must  treat  the  patient,  not  the 
disease.  In  pursuance  of  this  object,  we  should,  if  possible,  ascertain 
the  etiology  of  the  affection.  In  a  large  proportion  of  cases  this  is  im- 
possible, and  in  others  the  cause  cannot  be  removed,  even  when  known. 
But  in  a  certain  number,  especially  in  reflex  epilepsy,  the  cause  cannot  only 
be  determined  but  can  also  be  readily  made  to  disappear.  It  is  unneces- 
sary for  me  to  refer  again  to  these  etiological  factors,  as  they  have  been 
discussed  in  extenso  in  the  section  on  etiology,  and  their  treatment  be- 
longs partly  to  surgery,  partly  to  other  branches  of  medicine.  The 
treatment  of  diseases  of  the  ear,  throat,  chest,  genital  organs,  etc.,  which 
act  as  causes  of  the  epileptic  seizure,  is  similar  to  that  usually  resorted 
to  in  such  affections.  The  prominence  which  has  been  attached  to 
trephining  for  injuries  of  the  skull  which  have  acted  as  causes  of  epi- 
lepsy, requires  that  we  should  enter  into  this  subject  somewhat  more 
fully.  There  is  no  doubt  that  the  advocates  of  trephining  for  epilepsy 
have  entertained  exaggerated  views  with  regard  to  the  influence  of  in- 
juries of  the  skull,  in  the  production  of  the  disease.  Among  3,000  cases 
of  epilepsy,  Althaus  did  not  find  a  single  one  which  presented  fracture 
of  the  cranial  bones,  with  depression  of  the  skull.  Several  cases  have 
come  under  my  notice  in  which  the  disease  was  supposed  to  be  due  to 
injury  of  the  skull,  although  careful  inquiry  showed  no  grounds  for  this 
assertion.  As  we  have  before  remarked,  the  statements  of  patients  or 
their  relatives  with  reference  to  etiology  should  always  be  subjected  to 
careful  scrutiny  before  being  accepted.  In  examining  the  favorable 
statistics  with  regard  to  the  effects  of  trephining  which  have  been 
advanced  by  several  writers,  we  must  take  into  consideration  the  fact 
that,  as  a  rule,  the  unfavorable  cases  are  not  reported,  and  furthermore, 
that  a  considerable  proportion  of  the  favorable  ones  have  been  published 
within  a  few  months  after  the  operation,  at  a  period,  therefore,  in  which 
it  is  unwarrantable  to  draw  any  conclusions  with  regard  to  the  final 
result. 

On  the  whole,  therefore,  we  should  not  advise  the  performance  of 
trephining,  unless  the  epilepsy  evidently  followed  an  injury  to  the  skull, 
which  was  accompanied  by  distinct  fracture  of  the  bones,  with  depres- 
sion. If  irritation  of  the  injured  part  is  capable  of  producing  a  con- 
vulsion, the  indications  for  the  operation  are  rendered  much  stronger. 

In  cases  of  syphilitic  epilepsy,  the  indications  for  treatment  are  very 
clear.     When  the  convulsions  occur  during  the   early  secondary  stage, 


84  FUNCTIONAL    NEKVOUS   DISEASES. 

as  in  the  form  recently  described  by  Fournier,  mercurial  treatment  i» 
alone  required.  When  the  attacks  occur  during  the  tertiary  stage,  and 
are  either  svie  materia,  or  form  part  symptom  of  other  manifestation* 
of  cerebral  syphilis,  iodide  of  potassium  should  also  be  administered  in 
combination  with  mercury.  If  the  disease  has  not  lasted  too  long,  the 
prognosis  is  very  good,  but  we  cannot  afford  to  use  the  drug  in  homoeo- 
pathic doses.  I  usually  administer  the  mercurial  separately  from  the 
iodide,  as  the  latter  must  be  increased  very  much  more  rapidly  than  the 
former.  The  iodide  of  potassium  is  first  given  in  fifteen-grain  doses- 
three  times  a  day,  from  one-twenty-fourth  to  one-sixteenth  of  a  grain  of 
the  bichloride  of  mercury  being  exhibited  at  the  same  time.  In  a  week^ 
the  quantity  of  iodide  may  be  increased  by  half,  and  if  a  fit  has  occur- 
red in  the  interim,  the  dose  may  be  doubled.  The  quantity  is  gradually 
increased  in  this  manner  until  the  iodide  eruption  makes  its  appearance  or 
the  stomach  begins  to  revolt.  If  this  quantity  succeeds  in  preventing  the 
occurrence  of  the  fits,  the  amount  is  slightly  reduced,  and  the  patient  held 
at  this  dose.  If  the  attacks  continue,  the  quantity  of  iodide  administered 
should  be  increased  until,  if  necessary,  half  an  ounce,  or  even  an  ounce,  is- 
taken  per  diem.  When  such  large  amounts  are  administered,  I  usually 
order  thirty  grains  of  subnitrate  of  bismuth,  with  five  or  ten  grains  of  the 
bicarbonate  of  soda,  to  be  taken  before  each  dose  of  the  iodide,  in  order 
to  counteract  the  irritating  effects  of  the  latter  upon  the  gastric  mucous 
membrane.  These  patients  often  suffer  from  violent  headache.  In  such 
cases,  frequently  repeated  blisters,  applied  to  the  nape  of  the  neck,  prove 
very  serviceable;  in  others  resort  may  be  had  to  the  use  of  the  actual 
cautery,  but  I  have  not  derived  so  much  benefit  from  this  measure  as 
from  the  application  of  blisters. 

One  great  drawback  against  which  we  have  to  contend  in  these 
patients  is  owing  to  the  fact  that  they  are  apt  to  discontinue  the  remedy 
as  soon  as  the  fits  have  ceased  for  a  couple  of  months.  This  is  a  great 
mistake,  and  I  always  make  it  a  rule  to  forcibly  impress  upon  my  patient 
the  necessity  of  continuing  treatment  for  a  year  and  a  half  or  even 
two  years  after  the  last  fit  occurred.  A  patient  who  has,  at  any  time, 
had  manifestations  of  cerebral  syphilis,  is  always  liable  to  a  relapse,  and 
this  can  only  be  prevented  by  the  long-continued  and  faithful  use  of  the 
iodide.  We  must  also  bear  in  mind  that  the  quantity  to  be  administered 
is  not  regulated  by  the  dose  laid  down  in  the  materia  medica,  but  by  the 
effect  produced  upon  the  patient. 

When  the  attacks  are  due  to  excessive  sexual  intercourse,  or  to 
masturbation,  such  practices  must,  of  course,  be  interdicted.  But  while 
the  former  cause  can  be  easily  removed  in  the  majority  .of  cases,  the 
latter  desideratum  is  not  so  readily  obtained.  If  the  masturbator,  usual- 
ly a  child,  has  a  narrow  prepuce  which  is  causing  irritation  of  the  glans, 
it  should  be  circumcised,  and  I  have  recently  had  a  case  in  which  the 
fits  have  remained  absent  for  the  last  four  months  since  the  operation, 
no  other  treatment  having  been  adopted.  In  girls,  in  whom  no  local 
treatment  can  be  employed,  we  can  only  resort  to  careful  watching  of 
the  patient  by  the  relatives.  I  also  usually  recommend  that  the  patient 
be  compelled  to  sleep  with  an  adult,  as  I  have  found  that  many  of  the 
little  patients  Avill  masturbate  as  soon  as  they  get  warm  in  bed.  In  those 
rare  cases  in  which  the  attacks  develop  during  coitus,  tlie  performance  of 
the  sexual  act  must,  of  course,  be  strictly  prohibited. 

But,  as  we  have  shown  in  the  chapter  on  etiology,  in  the  majority  of 
cases  the  cause  is  either  unknown  or  is  of  such  a  nature  that  it  cannot 


EPILEPSY.  85 

be  relieved  either  by  surgical  or  medical  measures.  We  must  also  re- 
member that  a  considerable  proportion  of  the  cases  of  reflex  epilepsy  only 
come  to  us  for  treatment  several  years  after  the  cause  first  began  to  ope- 
rate, and  that,  in  many  of  these  patients,  the  epilepsy  has  acquired  an 
independent  existence,  and  will  not  disappear,  even  though  the  original 
cause  be  successfully  removed.  In  the  large  majority  of  cases,  therefore, 
we  can  only  treat  the  disease  symptomatically. 

The  treatment  of  epilepsy  may  be  divided  into  two  parts,  viz. :  the 
use  of  general  and  medicinal  remedies.     We   shall  first  study  the  former. 

There  is  a  widespread  notion  in  the  profession,  as  well  as  among  the 
laity,  that  epileptics  must  be  kept  idle;  that  they  should  not  be  allowed 
to  do  either  any  mental  or  physical  labor.  This  view  is  undoubtedly  er- 
roneous. With  regard  to  mental  exercise,  there  is  no  doubt  that  the  ten- 
dency of  the  disease  itself  is  to  produce  deterioration  of  intellect,  and 
this  mental  infirmity  will  be  increased  by  allowing  the  patients  to  grow 
up  uneducated.  It  is  true,  however,  that  excessive  mental  work  will  ag- 
gravate tlie  frequency  of  the  occurrence  of  the  fits.  In  fact  there  are 
some  patients  wiio  only  have  a  convulsion  after  they  have  undergone 
some  severe  or  prolonged  mental  strain.  Continued  reading  is  especially 
injurious  to  epileptics.  But  we  must  not  fall  into  the  other  extreme,  and 
debar  them  from  all  reading.  It  is,  indeed,  not  alone  not  injurious  to 
allow  them  to  read,  attend  lectures,  amusements,  etc.,  but  it  is  even  bene- 
ficial when  confined  within  proper  limits.  Such  a  course  of  conduct 
tends  to  preserve  the  mental  tone  of  the  patient  and  to  divert  his  atten- 
tion from  his  malady,  which  is,  otherwise,  always  uppermost  in  his  mind. 

This  practice  also  tends  to  prevent  the  patient  from  continuing  the 
habit  of  masturbation,  which,  when  it  once  gains  the  upperhand  in  an 
epileptic,  has  a  bad  influence  upon  the  frequency  of  the  attacks. 

These  remarks  will  also  apply  to  manual  labor;  the  patients  usually  do 
well  with  a  proper  amount  of  johysical  exercise.  Of  course  this  must  not 
be  excessive.  In  some  of  my  dispensary  patients  I  have  frequently  seen 
the  fits  increased  in  frequency  to  a  terrible  extent,  and,  upon  inquiry, 
have  found  that  this  could  be  attributed  to  overwork,  and  that  their 
number  immediately  diminished  when  the  character  of  the  work  was 
•changed. 

When  patients,  whether  male  or  female,  have  become  epileptic  at  the 
age  of  puberty,  marriage  is  frequently  advised  by  the  physician  in  attend- 
ance. The  theory  on  which  this  advice  is  based,  appears  to  be  that  the 
epilepsy  is  due  to  some  unknown  derangement  of  the  sexual  system,  and 
that  this  will  disapppear  in  consequence  of  the  regular  performance  of 
the  sexual  act.  A  few  cases  are  on  record  which  appear  to  substantiate 
this  view,  but  they  are  very  exceptional.  It  must  also  be  remembered 
that,  even  in  some  of  these  cases,  although  the  epilepsy  disappeared  in 
the  parent,  it  reappeared  in  the  offspring. 

But  the  majority  of  writers  are  opposed  to  the  marriage  of  epileptics. 
In  Denmark  this  matter  has  become  the  subject  of  legislative  interfer- 
ence, and  the  fact  that  one  party  to  a  marriage  was  an  epileptic  prior  to 
the  marriage,  without  the  knowledge  of  the  other,  constitutes  a  valid 
ground  for  divorce.  We  believe  that  this  is,  theoretically,  the  proper 
plan  to  pursue.  Even  if  we  hold  that  marriage  will  prove  curative  of  the 
affection,  the  risk  which  the  parent  runs  of  transmitting  this  terrible  dis- 
ease to  the  offspring  is  so  great  that  he  should  be  warned  against  mar- 
riage. Although  there  is  no  legislation  on  the  subject  in  this  country, 
the  medical  profession  can  do  a  great  deal  toward  preventing  such  alii- 


86  FUNCTIONAL    NERVOUS    DISEASES. 

ances.  In  the  event  that  our  advice  in  this  respect  is  disregarded,  as  it 
so  frequently  is,  it  becomes  a  grave  question  whether  it  is  not  our  moral 
duty  to  override  the  letter  of  the  code,  and  inform  the  other  partner  in 
the  projected  marriage  of  the  actual  state  of  affairs. 

If  the  general  condition  of  the  patient  is  below  par,  the  ordinary  tonic 
remedies,  such  as  iron,  quinine,  cod-liver  oil,  etc.,  should  be  administered. 
Some  authors  have  discountenanced  the  use  of  iron  in  this  disease,  be- 
cause it  tends  to  produce  plethora.  In  order  to  test  the  truth  of  this 
statement,  I  have  often  given  iron,  not  alone  to  anaemic  epileptics,  but 
also  to  those  Avho  were  in  excellent  general  health.  I  have  yet  to  find 
any  bad  effects  from  its  administration. 

Opinions  vary  with  regard  to  the  diet  of  epileptics.  The  notion  has 
become  prevalent  among  the  laity,  and  is  even  widespread  among  phy- 
sicians, that  nitrogenized  food  should  be  sparingly  partaken. 

Thus,  Hughlings  Jackson  advises  that  epileptics  should  not  eat  much 
nitrogenized  food,  nor,  indeed,  much  of  any  kind  of  food,  basing  his  opin- 
ion on  the  view  that  the  nervous  tissues  in  this  disease  are  over-nourished 
with  regard  to  quantity. 

Dr.  Merson,'  who  made  some  extended  observations  on  this  question, 
arrived  at  the  following  conclusions:  "In  a  considerable  number  of 
those  who  took  nitrogeneous  food  during  the  first  month,  it  was  observed 
that  soon  after  commencing  that  diet  they  became  much  more  dull  and 
stupid  than  they  had  previously  been,  would  sit  in  a  dreamy,  listless 
manner  for  a  great  part  of  the  day,  were  very  slow  and  languid  in  their 
movements,  and  took  little  notice  of  what  was  going  on  around  them. 
No  relation  was  traced  between  it  and  the  recurrence  of 
the  fits.  As  soon  as  the  diet  was  changed  to  the  farinaceous,  it  was 
remarked  that  the  condition  of  hebetude  began  to  pass  off,  and  in  some 
of  the  cases  the  change  was  very  remarkable.  The  improvement  in  the 
mental  condition  was  not  always  accompanied  by  any  marked  diminution 
in  the  number  of  fits."  Merson  continued  his  experiments  for  two 
months,  and  found  a  slight  decrease  in  the  number  of  fits  in  a  large  pro- 
portion of  the  patients  who  were  kept  on  a  farinaceous  diet,  but  the  dif- 
ference was  not  very  marked. 

The  results  obtained  by  this  experimenter  are  not  decided  enough  to 
be  very  convincing.  My  own  experience  leads  me  to  believe  that  it  is 
unnecessary  to  limit  the  quantity  or  quality  of  the  food,  with  the  excep- 
tion that  all  heavy,  indigestible  substances  are  to  be  avoided,  as  well  as 
strong  tea  or  coffee.  The  use  of  spirituous  liquors  should  also  be  care- 
fully interdicted. 

We  now  turn  to  the  medicinal  agents  which  are  employed  to  combat 
the  disease  itself.  The  number  of  drugs  which  have  been  used  in  the 
treatment  of  epilepsy  is  legion,  and  a  couple  of  pages  could  be  filled 
with  their  mere  enumeration,  I  shall,  however,  only  mention  those 
which  have  proven  useful  in  my  own  practice.  In  considering  the 
remedial  effects  of  any  agent  in  this  disease,  we  must  bear  in  mind  that 
any  change  is  apt  to  prove  beneficial  for  a  time.  Thus,  if  the  adminis- 
tration of  one  drug  is  stopped  and  another  is  substituted  for  it,  the 
number  of  fits  will  be  frequently  diminished  for  several  weeks  or  even 
months,  after  which  they  resume  their  former  frequency. 

Bromide  of  potassium  is  by  far  the  most  potent  of  all  remedies. 
Various  other  bromides  (sodium,  ammonium,  etc.)  have  been  employed 

'  West  Riding  Lunatic  Asylum,  Med.  Rep.  V.,  1875. 


EPILEPSY.  87 

in  preference,  but  I  have  never  seen  them  succeed  where  the  potash  salt 
failed.  It  produces  a  considerable  amount  of  improvement  in  the  major- 
ity of  cases,  in  others  it  is  entirely  useless,  and  in  a  few  its  administra- 
tion must  be  discontinued,  as  the  patients  grow  steadily  worse.  I  have 
found  that  the  latter  event  is  more  apt  to  occur  in  cases  of  nocturnal 
epilepsy  or  in  petit  mal.  The  character  of  the  fits  often  changes  under 
the  influence  of  this  drug.  As  an  indication  of  improvement,  we  some- 
times find  that  the  aura  alone  develops  at  times,  the  convulsions  remain- 
ing absent.  Exceptionally,  I  have  also  noticed  that  in  cases  in  which  the 
convulsions  had  previously  occurred  without  an  aura,  the  latter  symptom 
developed  under  the  influence  of  the  bromides.  The  mental  symptoms 
also  undergo  improvement  ;  the  irritable  temperament  may  disappear, 
the  dull,  stupid  expression  vanishes,  and  the  patients  may  acquire  a 
greater  interest  in  the  affairs  going  on  around  them. 

The  manner  in  which  the  drug  is  administered  must  be  carefully  reg- 
ulated. When  benefit  is  derived  from  this  remedy  it  should  be  continued 
uninterruptedly  for  years,  and  I  always  make  it  a  rule  to  administer  it 
for  at  least  two  years  after  the  last  convulsion  has  occurred.  The  initial 
dose  is  fifteen  grains,  t.i.d.,  taken  preferably  on  an  empty  stomach 
(about  three  hours  after  meals),  and  in  plenty  of  water.  When  the 
stomach  is  dainty,  it  may  be  combined  with  a  little  bicarbonate  of  soda 
and  a  simple  bitter.  Dr.  E.  C.  Seguin  advises  its  administration  in 
Vichy  water,  and  I  can  also  recommend  this  plan  as  very  satisfactory. 
In  cases  of  nocturnal  epilepsy  a  double  dose  should  be  taken  at  night. 
The  quantity  administered  should  be  gradually  increased  until  slight 
bromism  is  produced  (irritability  of  the  stomach,  acne  eruption,  anaes- 
thesia of  the  pharynx  and  velum  palati,  fetid  breath,  feeble  pulse,  drow- 
siness). Different  patients  vary  greatly  in  this  respect,  and  I  have  some- 
times given  three  drachms  daily  for  several  weeks  at  a  time  before  any 
symptoms  of  bromism  became  apparent.'  When  these  symptoms  develop, 
the  quantity  administered  must  be  diminished,  or  the  drug  entirely  with- 
held for  a  few  days.  My  own  experience  is  corroborative  of  that  of  Dr. 
Seguin  who  found  that  the  acne-eruption  of  bromism  may  be  held  some- 
what in  check  by  the  administration  of  small  doses  of  Fowler's  solution. 
After  the  bromism  has  subsided  the  remedy  is  continued  in  somewhat 
smaller  doses  for  a  few  months,  at  least,  before  it  is  renounced  as  useless. 
The  patients  should  be  strongly  impressed  with  the  idea  that,  under  no 
consideration,  should  the  bromide  be  discontinued,  unless  under  the 
advice  of  the  physician.  If  patients,  who  formerly  had  a  number  of  fits 
per  week,  go  several  months  without  a  convulsion,  they  often  consider 
themselves  cured,  and  omit  the  medicine.  We  often  find,  in  such  cases, 
that  the  fits  return  after  a  very  short  intermission.  When  very  large 
doses  are  required  it  is  sometimes  advantageous  to  combine  the  bromides 
with  hydrate  of  chloral,  ten  to  fifteen  grains  of  the  latter  being  given  at 
a  time.  In  this  manner  we  can  diminish  the  amount  of  bromide  to  the 
point  of  tolerance  by  the  patient,  and,  in  some  cases,  the  chloral  appears 
to  have  a  special  remedial  action.  This  plan  should  not  be  continued, 
however,  for  a  very  long  time,  as  hydrate  of  chloral  soon  exerts  a  delete- 
rious influence  on  the  general  health. 

Belladonna  was  highly  praised  by  Trousseau  in  the  treatment  of  this 

'  Three  cases  have  come  to  my  notice  in  this  city,  in  which  death  was  due  to  over- 
doses of  bromide  of  potassium ;  the  condition  of  the  patients  should  therefore  be 
very  carefully  watched  when  large  doses  are  given. 


88  FUNCTIONAL    NERVOUS    DISEASES. 

disease,  and  other  observers  have  also  reported  favorable  results  from  the 
use  of  this  remedy.  At  the  present  time  atropia  is  used  in  preference,  as 
the  alkaloid  is  much  more  constant  in  its  effects,  and  the  dose  can  there- 
fore be  graduated  more  carefully.  My  experience  with  it  in  diurnal  at- 
tacks of  grand  mal  has  not  been  very  satisfactory;  at  the  most  I  have 
merely  noticed  a  slight  diminution  in  the  frequency  of  the  convulsions. 
In  nocturnal  epilepsy,  however,  and  especially  in  the  various  forms  of 
petit  mal,  I  have  derived  marked  benefit  from  this  drug.  It  should  be 
begun  in  doses  of  ^^  grain,  repeated  three  times  a  day,  and  gradually  in- 
creased until  dilatation  of  the  pupils  occurs;  it  should  not  be  pushed  be- 
yond this  slight  physiological  effect.  As  an  example  of  the  rapid  im- 
provement which  sometimes  occurs,  I  may  refer  to  the  patient  mentioned 
on  page  52,  in  whom  the  disease  had  lasted  for  four  years  before  coming 
under  treatment,  and  who  had  three  or  four  attacks  of  petit  mal  daily. 
As  soon  as  the  patient  was  brought  under  the  influence  of  atropine  the 
attacks  disappeared,  and  during  the  entire  period  in  which  she  was  un- 
der observation  (upward  of  a  year),  no  attacks  occurred  unless  the  drug 
had  been  discontinued  for  a  few  days.  The  memory  also  improved  very 
rapidly. 

Strychnia  has  been  very  little  used  in  epilepsy,  but  I  have  sometimes 
obtained  excellent  results  in  cases  similar  to  those  in  which  I  employ 
atropine,  viz.,  in  nocturnal  attacks  and  in  petit  mal,  especially  in  the 
former.  In  such  cases  it  is  sometimes  combined  to  advantage  with  bro- 
mide of  potassium.  The  dose  varies  from  one-forty-eighth  to  one-thirty- 
second  of  a  grain  three  times  a  day,  and  continued  uninterruptedly  so 
long  as  it  produces  good  results.  It  possesses  the  advantage  of  acting  as 
a  nerve  tonic,  and  may  be  continued  for  a  long  time  without  producing 
any  deleterious  effects  on  the  economy.  Conium  is  sometimes  used  in 
this  disease,  but  I  have  usually  given  it  in  combination  with  bromide  of 
potassium,  when  the  latter  does  not  give  sufficiently  good  effects.  The 
dose  is  five  drops  of  the  fluid  extract,  gradually  increased.  The  remedy 
must  be  exhibited  very  cautiously,  as  some  patients  are  very  susceptible 
to  its  influence,  and  it  readily  produces  symptoms  of  poisoning. 

Quite  a  number  of  metallic  remedies  have  been  employed  from  time 
to  time,  but  we  shall  content  ourselves  with  mentioning  two,  viz.:  nitrate 
of  silver  and  oxide  of  zinc.  Nitrate  of  silver  for  a  long  time  occupied  a 
prominent  part  in  the  treatment  of  epilepsy,  and  some  undoubted  cases 
of  recovery  have  occurred  under  its  use.  At  the  present  time,  however, 
it  is  very  rarely  administered,  and  this  is  undoubtedly  due,  in  part,  to  the 
fact  that  patients  are  occasionally  met  whose  entire  integument  has  be- 
come'blue  from  the  long-continued  use  of  the  drug,  while  the  epileptic 
convulsions  have  persisted  with  all  their  original  severity  and  frequency. 

Oxide  of  zinc  appears  to  be  gaining  more  favor  recently  than  it 
formerly  enjoyed.  It  is  employed  either  alone  or  in  combination  with 
bromide  of  potassium,  in  doses  of  five  to  ten  grains,  which  may  be  grad- 
ually increased  to  twenty  grains.  I  have  seen  good  effects  from  it  when 
given  in  both  ways,  but  do  not  think  that  it  can  compare  with  the  bro- 
mides in  efficacy. 

In  those  cases,  however,  in  which  the  bromides  are  useless,  or  the  other 
remedies  mentioned  above  are  not  indicated,  faithful  trial  should  be  made 
of  the  zinc  salt.  Valerianate  of  zinc  has  also  been  recommended,  but  it 
possesses  no  advantage  over  the  oxide;  in  addition,  it  is  extremely  dis- 
agreeable to  the  task. 

Nitrite  of  amyl   has   recently  come  into  vogue  in  the   treatment   of 


EPILEPSY.  89 

epilepsy,  especially  when  the  convulsions  are  preceded  by  an  aura.  It 
should  always  be  used  whenever  the  warning  is  sufficiently  long  to  enable 
the  patient  to  inhale  it  before  the  fit  begins.  The  dose  varies  from  two 
to  five  drops  (by  inhalation),  and  even  more  may  be  required,  as  some 
patients  become  very  quickly  habituated  to  its  effects.  A  convenient 
plan  consists  in  keeping  a  single  dose  of  the  amyl  in  thin  capsules  of 
glass,  which  can  be  carried  in  the  pocket,  and  crushed  in  the  fingers  as 
required.*  If  the  patient  is  too  poor  to  afford  this  expense,  he  may  keep 
a  dose  of  the  remedy  in  a  small  glass  vial,  and,  when  he  feels  the  fit  com- 
ing on,  can  pour  the  amyl  into  the  palm  of  his  hand  and  then  inhale  it. 
By  some  physicians  it  is  administered  regularly  in  three  to  five  drop  doses, 
t.i.d. ;  I  have  tried  this  plan  in  a  few  cases,  but  have  not  derived  any 
benefit  from  it.  When  given  during  the  aura,  however,  it  very  frequent- 
ly aborts  the  attack,  and  in  this  manner  may  very  decidedly  reduce  the 
number  of  convulsions.  Some  of  the  patients  complain  that  when  a  fit 
does  occur  under  such  circumstances  it  is  more  than  usually  severe. 

Nitrite  of  amyl  has  also  proved  of  decided  advantage  in  the  treatment 
of  the  status  epilepticus,  and,  in  fact,  appears  to  be  the  only  agent  which 
promises  any  chances  of  success  in  this  complication.  In  these  cases, 
however,  much  larger  doses  are  required,  and  as  many  as  ten  to  fifteen 
drops  are  often  necessary. 

Galvanism  has  recently  been  employed  in  this  disease,  but  the  major- 
ity of  observers  have  come  to  the  conclusion  that  it  is  entirely  useless. 

'  This  plan  was  devised,  I  believe,  by  Dr.  McBride  of  this  city. 


N'ETJEALGIA. 


CHAPTER  I. 

CLINICAL  HISTORY. 


Neuralgia  is  a  paroxysmal  disease,  and  is  chiefly  characterized 
(sometimes  solely)  by  the  presence  of  pain.  This  appears  under  peculiar 
conditions  which  distinguish  it  from  other  painful  affections.  The  parox- 
ysm usually  begins  quite  suddenly,  although  it  is  sometimes  preceded  for 
a  little  while  by  sensations  of  cold,  numbness,  or  "  drawing  "  in  the  affected 
region.  Then  suddenly  a  twinge  is  felt  along  the  course  of  one  of  the 
nerves,  and  instantly  subsides,  to  be  followed  in  a  few  moments  by  an- 
other, and  then  by  another,  the  intervals  between  the  pains  growing 
gradually  or  rapidly  shorter,  until  finally  they  may  become  almost  con- 
tinuous. Their  character  is  variously  described  by  different  patients, 
sometimes  as  shooting,  darting,  lancinating,  boring,  twisting,  wrenching, 
"as  if  a  coal  of  fire  were  being  drawn  along  the  nerve,"  etc.  The  pains 
are  sometimes  truly  atrocious,  and  have  frequently  led  patients  to  commit 
suicide. 

The  paroxysm  develops  spontaneously,  or  in  consequence  of  some  very 
trifling  cause,  such  as  a  movement  of  the  lips  or  cheeks  while  speaking  or 
eating,  in  trigeminal  neuralgia,  or  a  slight  movement  of  the  foot,  in  sci- 
atica, etc.  The  pain  always  runs  along  the  anatomical  course  of  certain 
nerves,  and  usually  in  the  direction  from  the  centre  to  the  periphery,  al- 
though the  reverse  of  this  statement  sometimes  holds  good.  I  have  espe- 
cially observed  the  latter  state  of  affairs  in  brachial  neuralgias,  but  I  am 
unable  to  explain  the  reason  of  this  peculiarity.  Another  striking  char- 
acteristic of  a  large  number  of  neuralgic  affections  is  their  periodicity. 
In  those  which  are  due  to  malarial  influences  this  is  the  rule,  and  the  par- 
oxysm of  pain  occurs  with  the  same  regularity  as  the  chill  of  intermittent 
fever  ;  it  usually  assumes  the  quotidian,  sometimes  the  tertian  type,  but 
it  has  never,  in  my  experience,  occured  at  longer  intervals  than  on  alternate 
days.  But  periodicity  is  frequently  manifested  even  in  cases  which  are 
not  connected  with  malaria.  I  have  noticed,  however,  that  the  paroxysms 
are  more  apt  to  occur  in  such  cases  toward  the  middle  or  latter  part  of 
the  afternoon,  difPering  in  this  respect  from  the  former  variety.  Periodici- 
ty may  even  be  noticeable  when  the  neuralgia  is  due  to  an  organic  affec- 
tion of  the  nerves,  and  I  saw  it  so  well  marked  in  the  first  stages  of  a  case  of 
cancer  of  the  vertebrae  that  a  distinguished  physician  of  this  city,  who  saw 
the  patient  in  consultation,  at  first  made  a  diagnosis  of  malarial  neuralgia. 
The  subsequent  history  of  the  patient,  however,  showed  the  incorrectness 


92  FUNCTIONAL    NERVOUS    DISEASES. 

of  the  diagnosis,  and  the  case  finally  went  on  to  a  fatal  termination.  This 
peculiar  character  of  periodicity  is  not  restricted  to  neuralgia,  but  is  also 
common  to  other  nervous  affections,  and  no  very  satisfactory  explanation 
has  ever  been  offered  for  its  occurrence.  The  duration  of  the  paroxysms 
is  extremely  various  ;  sometimes  the}^  only  last  a  minute  or  tv^o,  some- 
times they  may  continue  for  several  da3's  or  even  longer,  v?ith  very  short 
intermissions.  As  a  rule,  the  duration  of  the  paroxysms  increases  with 
the  progress  of  the  disease,  and  those  which  occur  in  old  age  are  usually 
the  most  violent  and  prolonged. 

The  other  sensory  disturbances  include  the  puncta  dolorosa  or  painful 
points  described  by  Valleix,  and  which  were  considered  by  him  as  charac- 
teristic of  neuralgia.  This  term  refers  to  circumscribed  spots,  situated 
along  the  course  of  the  nerves,  where  they  emerge  from  bony  canals 
or  foramina,  where  they  pass  through  firm  aponeuroses,  or  where  they 
become  superficial  under  the  skin,  and  sometimes  under  the  mucous  mem- 
branes. Pressure  upon  these  localities  during  an  attack  of  neuralgia  pro- 
duces severe  pain  at  the  site  of  pressure,  and  may  also  reproduce  the  pain 
in  the  corresponding  nerve.  The  painful  points  are  sometimes  observed 
during  the  intervals  between  the  pai'oxysms,  though  not  by  any  means 
so  often  as  during  the  attacks.  If  the  skin  is  pinched  up  in  a  fold  over 
the  site  of  the  painful  point,  and  pressure  is  made  upon  the  integument, 
we  can  readily  determine  that  the  pain  is  not  due  to  hyper^esthesia  of  the 
skin.  In  fact,  the  reverse  is  sometimes  noticed,  and  the  integument  is 
found  to  be  decidedly  aneesthetic,  while  the  underlying  nerve  is  exquisitely 
tender  to  the  touch.  Valleix  stated  that  the  puncta  dolorosa  were  pres- 
ent in  almost  all  cases  of  neuralgia,  but,  in  common  with  a  great  number 
of  other  observers,  I  have  found  them  absent  in  a  large  percentage  of 
cases.  It  would,  therefore,  be  unwise  to  exclude  the  diagnosis  of  neu- 
ralgia from  the  absence  of  the  painful  points. 

Trousseau,  in  combating  Valleix's  view  of  the  pathognomonic  char- 
acter of  this  symptom,  called  attention  to  the  presence  of  the  point  apo- 
physaire,  or  spinal  point,  as  characteristic  of  neuralgia.  He  states  that 
"  the  spinous  point,  as  its  name  indicates,  is  situated  over  the  spinous 
processes  of  the  vertebrae,  and,  since  my  attention  has  been  drawn  to  it, 
I  have  never  known  it  to  be  absent."  The  spinous  point  usually  corre- 
sponds to  that  vertebra  from  which  the  affected  nerve  emerges,  but  it  is  a 
remarkable  circumstance  that  a  tender  spot  is  sometimes  feic  upon  press- 
ure over  the  first  or  second  cervical  vertebra  in  cases  of  trigeminal  neu- 
ralgia. I  have  observed  this  in  quite  a  number  of  instances,  and,  in  some 
have  succeeded  in  sending  a  thrill  of  pain  through  the  affected  fifth  nerve 
by  pressing  upon  the  spinous  processes  of  the  tender  vertebrge.  At  times 
pain  is  not  produced  by  pressing  upon  this  part  itself,  but  will  develop 
when  pressure  is  made  immediately  to  one  side.  In  such  cases,  T  have 
always  found  that  the  painful  spot  was  situated  upon  the  same  side  as 
the  neuralgia.  But  these  "  spinous  points  "  are  not  by  any  meaijs  so 
frequent  as  Trousseau  believed,  and,  in  fact,  great  caution  must  be  exer- 
cised in  determining  their  presence,  especially  in  females.  We  should 
never  rest  satisfied  with  one  examination,  but  should  press  upon  the  ver- 
tebrae several  times  in  succession,  and  at  the  same  time  endeavor  to 
divert  the  attention  of  the  patient  from  the  object  of  the  examination. 
If  one  of  the  processes  is  really  tender,  pressure  upon  it  will  produce  a 
change  in  the  expression  of  the  face,  which  is  more  reliable  than  the  mere 
statement  of  the  patient.  If  we  pay  attention  to  all  these  details,  we 
will  soon  come  to  the  conclusion  that  a  large  proportion  of  the  spinous 


NEURALGIA.  93 

points  are  purely  imaginary.  Although  we  do  not  attach  the  same  diag- 
nostic importance  to  the  points  ajyophysaires  as  was  attributed  to  them 
by  Trousseau,  they  possess  consideral)le  importance  with  regard  to  thera- 
peutics, as  we  will  endeavor  to  show  in  the  chapter  on  treatment. 

Hypeniesthesia  and  anresthesia  in  the  distribution  of  the  affected 
nerves  are  frequently  observed.  They  were  first  described  by  Tuerck,  in 
1850,  and  later  by  Trousseau,  who  thought  that  the  presence  of  ansesthesia 
"Was  indicative  of  deep-seated  nerve  lesions.  Nothnagel'  has  studied  this 
subject  very  thoroughly,  and  finds  that  hyperassthesia  is  primary,  and 
lasts  from  two  to  eight  weeks,  and  is  then  followed  by  anresthesia.  Erb's 
observations  corroborate  those  of  Nothnagel  to  a  gr':*at  extent,  but  the 
former  author  has  also  determined  the  existence  of  anaesthesia  in  the 
first  week  of  the  disease;  in  some  cases  no  sensory  disturbances  have  been 
noted.  In  a  few  instances  the  hyperaesthesia  or  anaesthesia  were  diffused 
over  the  entire  corresponding  half  of  the  body. 

Attention  must  also  be  drawn,  at  this  point,  to  the  frequent  presence 
of  irradiated  pains  in  other  parts  of  the  body.  Thus  it  is  not  at  all  in- 
frequent that,  at  the  height  of  a  paroxysm  of  trigeminal  neuralgia,  pain 
is  felt  in  the  occipitalis  major  nerve  on  the  same  side;  the  development 
of  trigeminal  neuralgia  during  the  course  of  cervico-occipital  neuralgia  is 
observed  with  less  frequency.  At  times,  however,  the  irradiation  may 
occur  to  remote  parts  of  the  body,  as  is  observed  in  the  development 
of  trigeminal  pain  during  the  course  of  sciatica.  The  irradiated  pains  are 
usually  not  so  severe  as  those  of  the  primary  paroxysm,  and  they  only 
develop  when  the  latter  attains  considerable  intensity. 

In  a  large  percentage  of  cases  the  symptoms  which  we  have  described 
above  are  the  only  ones  observed,  and  they  may  be  unaccompanied  by 
any  others  during  the  whole  course  of  the  affection.  But  severer  cases, 
and  sometimes  even  milder  ones,  may  be  accompanied  by  various  motor, 
vaso-motor,  secretory,  and  trophic  disturbances,  which  may  prove  much 
more  serious  than  the  primary  affection. 

We  will  find,  during  our  consideration  of  special  neuralgias,  that 
while  the  motor,  vaso-motor,  and  secretory  complication  are  much  more 
frequent  than  the  trophic  disorders,  the  latter  are  more  important,  and 
will  also  merit  careful  attention. 

Motor  cotnjylications. — When  the  neuralgia  affects  purely  sensory 
branches  of  a  nerve,  the  motor  complications  are  necessarily  reflex;  when 
the  nerve  is  mixed,  they  are  usually  manifested  in  the  course  of  the  same 
nerve,  though  even  in  the  latter  instance  they  may  be  radiated  to  other 
branches. 

The  reflex  complications  are  best  seen  in  tic  douloureux,  in  which  the 
muscular  twitchings,  induced  by  the  neuralgia  of  the  fifth  pair,  appear 
in  the  facial  muscles  which  are  supplied  by  the  seventh.  They  vary  from 
slight  fibrillary  twitchings  to  well-marked  and  rapid  convulsive  movements. 
The  convulsive  phenomena  occurring  in  the  course  of  the  affected  nerve 
are  best  observed  in  sciatica,  and  I  have  sometimes  seen  the  limb  raised 
violently  from  the  ground  in  the  course  of  this  affection.  Paralyses  have 
also  been  noticed  during  neuralgias,  but  although  they  have  been  de- 
scribed during  the  first  stages,  I  have  never  observed  them  until  the 
neuralgia  has  lasted  for  a  long  time.  The  paralysis  is,  of  course,  most 
marked  in  the  limbs,  and  I  have  seen  considerable  loss  of  power  in  invet- 
erate sciatica.     This  can  be   readily  distinguished  from  the  immobility 

'  Virch.  Arch.  BJ.  54,  1873. 


94  FUNCTIONAL    NERVOUS    DISEASES. 

of  the  parts  caused  by  a  dread  of  the  renewal  of  the  pain  on  motion,  and 
in  my  experience  has  always  been  attended  with  considerable  atrophy  of 
the  muscles — an  atrophy  which  T  could  not  entirely  explain  on  the  theory 
of  the  disuse  of  the  muscles,  and  which  I  was  therefore  compelled  to 
regard  as  a  trophic  change. 

Vaso-motor  complications. — These  are  not  very  numerous  or  impor- 
tant. During  the  paroxysms  the  arteries  leading  to  the  affected  region 
are  frequently  dilated  and  pulsate  strongly  and  visibly;  the  surface  of  the 
body  is  red  and  hot,  and  its  temperature  is  somewhat  raised  when  com- 
pared with  the  corresponding  part  of  the  body  on  the  opposite  side.  In 
other  cases,  on  the  contrary,  the  reverse  is  observed,  the  skin  is  pale  and 
cool,  and  slight  rigors  are  experienced  in  the  affected  region.  A  certain 
amount  of  oedema  of  the  subcutaneous  cellular  tissue  may  develop  during 
a  paroxysm,  but  it  is  never  very  marked,  and  usually  disappears  shortly 
after  the  termination  of  the  attack. 

Secretory  complications. — These  are  observed  almost  exclusively  in  tri- 
geminal neuralgia,  because  this  is  almost  the  only  form  in  which  a  nerve 
is  affected  which  possesses  an  influence  over  any  of  the  secretions. 

For  this  reason  we  prefer  to  postpone  their  discussion  until  the  con- 
sideration of  the  special  varieties  of  neuralgia. 

Tropjhic  complications. — We  now  enter  upon  an  extremely  interesting 
field  of  observation,  which  is  at  the  same  time  of  great  importance,  since 
the  effects  produced  are  frequently  of  a  lasting  character.  This  subject 
also  opens  up  the  question  of  the  existence  of  special  trophic  centres,  but 
the  character  of  this  article  precludes  our  entering  into  the  discussion. 
We  will  therefore  assume,  without  further  argument,  that  the  entire  series 
of  changes  which  we  shall  describe  in  this  section  are  due  to  an  affection 
of  special  trophic  nerves.  And  we  shall  first  take  into  consideration  the 
trophic  affections  of  the  skin. 

We  must  premise  our  remarks  by  the  statement  that  the  severest 
forms  of  cutaneous  trophic  disturbances  (glossy  skin,  deep  ulcerative 
eruptions,  etc.)  only  occur  when  the  nerves  are  seriously  injured  or  in- 
flamed, and  therefore  rarely  form  part  of  the  clinical  history  of  simple 
neuralgia. 

The  lesions  of  the  latter  include  simple  atrophy  of  the  entire  skin, 
which  appears  smoother  than  that  of  the  corresponding  part  of  the  body, 
is  thinner  than  on  the  opposite  side,  and  appears  to  be  more  shining  than 
normal.  In  one  case  I  also  observed  lesions  of  an  opposite  nature,  viz., 
hypertrophy  of  the  skin,  a  phenomenon  which  I  have  found  referred  to 
by  a  few  authors,  but  described  by  none.  The  patient  in  question  was 
suffering  from  neuralgia  of  all  three  branches  of  the  trigeminus  (the  mo- 
tor branch  was  also  involved,  and  the  case  will  be  again  referred  to  in  the 
chapter  on  peripheral  paralysis).  Upon  first  examining  him,  I  thought 
that  he  was  suffering  from  facial  paralysis  on  the  affected  side,  as  the 
face  remained  almost  motionless  on  that  side,  and  the  natural  folds  of  the 
skin  were  partially  effaced.  Upon  careful  investigation,  however,  I  found 
that  this  condition  of  affairs  was  due  to  hypertrophy  of  the  skin  (per- 
haps, also,  in  part,  of  the  subcutaneous  cellular  tissue),  which  was  dark, 
rough,  and  could  with  difficulty  be  pinched  up  into  a  fold.  The  apparent 
facial  paralysis  was  due  to  the  inability  of  the  muscles  to  move  the  thick 
and  stiff  integument,  although  there  was  no  reason  to  believe  that  the 
muscles  had  lost  their  power. 

The  skin  in  severe  neuralgia  is  also  apt  to  take  on  an  erysipelatous 
action,  which  presents  the  appearances  of   ordinary  erysipelas,  but  does 


NEURALGIA.  95 

not  run  a  severe  course,  and  never  endangers  the  life  of  the  patient.  Pig- 
mentation and  roughening  of  the  skin  have  been  noticed  by  several  ob- 
servers, notably  by  Anstie;  it  sometimes  disappears  after  the  paroxysm 
has  subsided.  In  one  case  I  saw  a  scaly  eruption  develop  in  the  course  of 
the  affected  nerve,  and  disappear  as  the  neuralgia  was  relieved.  Herpes 
zoster  constitutes  one  of  the  most  interesting  of  these  trophic  affections 
of  the  skin.  This  is  observed  almost  exclusively  in  trigeminal  and  intercos- 
tal neuralgias,  especially  in  the  latter,  appearing  sometimes  in  severe  and 
sometimes  in  the  course  of  mild  affections. 

The  eruption  appears  usually  on  the  right  side  of  the  body,  and  is 
strictly  limited  to  the  course  of  the  nerves;  in  very  rare  instances  it  ap- 
pears on  both  sides  at  the  same  time,  and,  if  it  is  situated  along  correspond- 
ing intercostal  nerves,  may  form  a  complete  zone  around  the  trunk.  The 
eruption  consists  of  large  vesicles,  situated  on  an  inflamed  base;  they 
contain,  at  first,  a  clear,  limpid  fluid  which,  at  a  later  period,  becomes 
cloudy  and  opaque;  the  vesicle  usually  ruptures  and  a  scab  forms,  which 
gradually  dries  and  disappears.  Sometimes  the  eruption  appears  before 
the  neuralgia,  but  usually  the  reverse  is  noticed.  This  eruption  may  pre- 
sent great  importance  on  account  of  the  peculiarity  of  its  site;  we  shall 
return  to  this  phase  of  the  subject  in  discussing  trigeminal  neuralgia. 

The  appendages  of  the  skin  may  also  become  involved  in  these  trophic 
changes.  The  hair  frequently  changes  its  color  during  the  paroxysms, 
and  is  restored  during  the  intervals.  One  of  my  patients,  a  woman  suffer- 
ing from  supra-orbital  and  occipital  neuralgia,  noticed,  during  each  par- 
oxysm, that  a  lock  of  hair  in  the  course  of  the  supra-orbital,  and  another 
in  the  course  of  the  occipitalis  major  nerve,  turned  gray,  but  that  the 
original  black  color  was  restored  after  the  paroxysm  had  subsided.  If 
this  process  is  frequently  repeated,  the  hair  may  finally  remain  perma- 
nently gray.  In  other  instances,  the  hair  acquires  a  coarser  and  more 
brittle  texture  (Anstie).  In  some  cases  the  hairs  have  a  tendency  to  fall 
out  (especially  in  neuralgias  of  the  nerves  of  the  limbs),  in  others  a  denser 
growth  develops  in  the  course  of  the  affected  nerves.  The  nails  may  be- 
come pale  and  discolored,  and  marked  by  irregular,  transverse  furrows; 
they  are  also  apt  to  be  clubbed  and  to  have  a  diminished  rate  of  growth. 
Under  such  circumstances  they  present  a  similar  appearance  to  that  ob- 
served in  certain  cases  of  cerebral  hemiplegia  which  are  attended  with 
trophic  changes  in  the  joints,  fingers,  and  toes.  Traumatic  neuralgias 
are  complicated  by  certain  other  more  profound  trophic  changes  of  the 
skin,  to  which  we  shall  refer  at  a  later  period. 

The  muscles  may  undergo  atrophy  quite  rapidly,  and  this  is  undoubt- 
edly a  trophic  change,  though  some  authorities  consider  it  merely  as  the 
effects  of  disuse.  But  this  is  negatived  by  the  fact  that  even  in  com- 
plete paralysis  of  the  limbs  in  consequence  of  cerebral  lesions,  very  little 
atrophy  occurs,  and  then  only  after  a  long  period  of  time.  Friedreich, 
however,  would  attribute  the  atrophy  in  such  cases,  as  he  does  in  progres- 
sive muscular  atrophy,  to  neuritic  changes  in  the  terminal  filaments  of  the 
nerves, 

Anstie  states  "  that  the  periosteum  of  bone  and  the  fibrous  fascije  in 
the  neighborhood  of  the  painful  points  of  neuralgic  nerves  not  unfre- 
quently  take  on  a  condition  of  subacute  inflammation,  with  marked 
thickening  and  tenderness  on  pressure."  It  is  difficult  to  determine, 
however,  whether  these  lesions  are  primary  or  secondary.  In  some  cases 
there  is  no  doubt,  from  the  clinical  history  of  the  affection,  that  the  peri- 
osteal  thickening  is  the  result  of  simple  or  rheumatic  chronic  inflamma- 


96  FUNCTIONAL    NERVOUS    DISEASES. 

tion,  and  has  acted  as  the  direct  cause  of  the  neuralgia,  on  account  of  its 
pressure  upon  the  nerves. 

The  trophic  disorders  of  the  organs  of  special  sense  will  be  discussed 
under  the  heading  of  trigeminal  neuralgia,  as  they  are  not  observed  in  any- 
other  forms  of  the  disease. 

Neuralgia  produces  various  degrees  of  reaction  upon  the  general  sys- 
tem, and  it  is  an  interesting  fact  that  these  effects  are  much  more  marked 
in  affections  of  the  trigeminus  than  in  other  varieties,  even  though  the 
latter  equal  the  former  in  intensity.  A  patient  may  suffer  for  years  from 
terrible  neuralgia  of  the  limbs,  -while  his  general  condition  remains  excel- 
lent, despite  the  helplessness  to  -which  he  may  be  doomed.  In  addition, 
these  neuralgias  do  not  often  produce  a  very  depressing  effect  upon  the 
mind,  although  I  once  observed  a  patient  -who  suffered  such  terrible  agony 
during  a  first  attack  of  sciatica  (and  after  the  paroxysm  had  only  lasted 
an  hour)  that  it  was  with  great  difficulty  he  was  prevented  from  com- 
mitting suicide.  The  ulterior  effects  of  trigeminal  neuralgia  are  much 
more  marked,  however,  although,  even  in  this  form,  many  patients  suffer- 
ing from  severe  and  intractable  pain,  present  a  perfectly  healthy  appear- 
ance. But  very  frequently  these  patients  are  forced  to  keep  themselves 
on  restricted  diet,  as  the  least  movement  of  the  jaws  in  deglutition  may 
suffice  to  develop  a  severe  paroxysm  of  pain,  and  they  prefer  to  starve 
themselves  rather  than  to  undergo  their  terrible  tortures.  Some  of  these 
sufferers  are  even  afraid  to  speak,  dreading  a  renewal  of  the  attack  from 
this  cause.  It  seems  to  me  that  intense  and  long-continued  pain  must 
markedly  diminish  the  nutritive  changes  occurring  in  the  economy,  as  I 
am  unable  to  explain,  in  any  other  way,  the  fact  that  the  loss  of  weight 
in  these  patients  is  not  commensurate  with  the  lessened  ingestion  of  food. 
Neuralgia  also  produces,  at  times,  serious  effects  upon  the  mind.  Apart 
from  the  suicidal  tendency,  which  so  frequently  arises  in  tic  douloureux, 
melancholia  is  apt  to  develop,  and  the  prognosis  as  regards  recovery  from 
the  mental  disturbance  is  not  very  good.  It  is  frequently,  however, 
difficult  to  determine  whether  the  melancholia  is  due  to  the  neuralgia,  or 
whether  they  are  both  the  expressions  of  a  deep-seated  disorder  in  the 
central  nervous  system.  The  family  history  is  sometimes  of  importance 
in  determining  this  point. 

There  is  very  little  to  be  said  with  regard  to  the  inter-paroxysmal 
period  of  neuralgia,  as  almost  the  entire  interest  centres  in  the  par- 
oxysms. During  the  intervals  pain  is  entirely  absent  in  mlid  cases,  but 
in  severe  ones  there  may  be  considerable  dull  pain  and  tenderness  along 
the  course  of  the  affected  nerves,  which  is  heightened  in  damp  weather, 
although  it  may  stop  short  of  a  paroxysm.  The  cutaneous  anaesthesia, 
to  which  we  referred  in  describing  the  paroxysms,  persists  in  severe  and 
chronic  cases,  during  the  intervals  of  the  attacks.  Many  of  the  trophic 
changes  to  which  we  called  attention  above,  also  continue,  and  may  even 
persist  after  the  primary  disease  has  entirely  subsided. 


CHAPTER  11. 

ETIOLOGY. 

General  Causes. 

Seredity. — As  in  a  large  number  of  other  functional  neuroses,  hered- 
ity plays  a  very  important  part  in  the  etiology  of  this  affection.  This 
fact  possesses  considerable  importance,  from  a  prophylactic,  as  well 
as  a  therapeutic  point  of  view.  Neuralgia  is  classed,  in  this  respect, 
with  epilepsy,  hysteria,  chorea,  insanity,  inebriety,  etc.  This  has  been 
most  strongly  and  clearly  shown  by  Anstie,  who  has  collected  a  consider- 
able number  of  cases,  in  which  the  hereditary  interchangeability  of  the 
various  neuroses  to  which  we  have  referred  is  very  distinctly  manifested. 
Anstie  appears  to  think,  moreover,  that  phthisis  in  the  parents  is  capa- 
ble of  giving  rise  to  the  development  of  neuralgia  in  the  offspring,  but, 
from  the  great  prevalence  of  the  former  disease,  we  should  be  inclined 
to  think  that  this  is  merely  a  coincidence.  At  all  events,  a  positive 
statement  concerning  such  a  relation  of  phthisis  and  neuralgia  could  only 
be  substantiated  by  a  very  large  and  accurate  array  of  statistics.  We  find 
sometimes  that  neuralgia  appears  in  several  children  belonging  to  the 
same  family,  although  there  is  nothing  in  the  family  history  of  the  an- 
cestors to  account  for  its  production.  In  one  case  of  this  kind  which 
came  under  my  notice,  the  children  of  one  of  the  parents  inherited  the 
neuralgic  tendency.  A  most  striking  proof  of  the  allied  nature  of  neu- 
ralgia and  various  functional  neuroses  is  its  interchangeability  with  them 
in  the  same  patient.  The  following  case  is  a  good  illustration  of  the 
combination  of  neuralgia  with  more  serious  neuroses:  Mrs.  I.  B.,  ast.  30 
years,  married;  one  brother  suffered  from  chorea;  all  her  brothers  and 
sisters  are  of  a  nervous  temperament.  I  could  get  no  history  of  nervous 
disease  in  her  parents  or  other  relatives.  The  patient  herself  suffered 
from  chorea  when  she  was  thirteen  years  old.  She  began  to  menstruate 
at  the  age  of  fourteen  years,  and  the  menses  have  been  regular  ever 
since.  At  the  age  of  sixteen,  she  had  an  attack  of  inflammatory  rheu- 
matism, and  soon  afterward  was  affected  with  trigeminal  neuralgia.  The 
patient  married  when  eighteen  years  old,  and  as  soon  as  she  became 
pregnant,  noticed  pains  "  like  jumping  toothache,"  in  the  back  of  the 
neck,  the  right  shoulder,  and  the  right  arm;  the  right  arm  was  cold,  and 
she  could  not  move  it  on  account  of  the  severe  pain  produced  thereby. 
During  the  next  six  years  the  patient  had  trigeminal  neuralgia  on  the 
right  side.  Five  years  ago,  she  again  became  pregnant,  and  suffered 
from  very  intense  sciatica,  which  continued  until  the  birth  of  the  child. 
Three  years  ago,  she  became  pregnant  a  third  time,  and  then  had  an  at- 
tack of  intense  lumbago;  she  began  to  act  strangely  during  this  preg- 
nancy, and  became  insane  when  the  child  was  seven  weeks  old.  She  was 
then  removed  to  an  asylum,  in  which  she  remained  for  thirteen  months 
(one  and  a  half  years  ago),  at  the  end  of  which  time  she  was  discharged 
7 


98  ruNCTioisrAL  nervous  diseases. 

.cured.  She  remained  well  until  six  weeks  ago.  The  patient  is  now  in 
the  seventh  month  of  pregnancy,  and  presents  a  very  angemic  appear- 
ance. There  is  no  oedema  to  be  detected  in  any  part  of  the  body,  and 
an  examination  of  the  urine  revealed  nothing  abnormal.  The  patient 
Avas  in  good  health,  since  her  discharge  from  the  asylum,  until  one  and  a 
half  months  ago,  when  she  began  to  complain  of  weakness,  palpitation 
of  the  heart,  and  shortness  of  breath  on  exercise.  At  this  time  she  also 
began  to  suffer  from  melancholy,  lost  her  spirits,  disliked  company,  and 
thought  that  "  something  terrible  was  going  to  happen  ";  she  also  suffered 
from  sleeplessness  during  this  time.  For  the  last  few  weeks,  she  has  be- 
gun to  complain  of  dull  pains,  interspersed  occasionally  with  shooting 
pains  in  the  right  shoulder;  during  the  past  week  she  has  suffered  from 
right  sciatica,  which  is  well  marked  at  the  present  time,  and  presents  all 
the  characteristic  symptoms.  She  states  that  she  feels  just  as  she  did  be- 
fore her  previous  attack  of  insanity.  The  patient  is  perfectly  regular  in 
her  habits;  does  not  indulge  in  stimulants  nor  excessive  sexual  inter- 
course. 

I  ordered  a  glass  of  porter  daily,  and  placed  the  patient  on  the  tinc- 
ture of  the  chloride  of  iron  internally,  and  administered  nitrite  of  amyl 
by  inhalation  (three  drops  three  times  a  day).  The  patient  began  to  im- 
prove immediately,  and  within  less  than  three  weeks  had  entirely  recov- 
ered, the  neuralgia  as  well  as  the  tendency  to  melancholia  having  disap- 
peared. Six  months  later  there  was  a  slight  return  of  the  former  symp- 
toms, but  a  few  days  of  similar  treatment  restored  the  patient  to  excel- 
lent health  and  spirits. 

It  is  not  extremely  unfrequent  to  find  that  neuralgia,  epilepsy,  and 
insanity,  appear  in  the  same  individual  at  different  periods  of  life.  In 
fact.  Trousseau  has  described  a  form  of  trigeminal  neuralgia  which  he 
calls  tic  epileptiform,  and  which  he  regards  as  very  similar  to  true  epi- 
lepsy. We  shall  refer  to  this  subject  again  in  describing  trigeminal  neu- 
ralgia. It  is  characteristic  of  those  neuralgias  which  are  due  to  heredity 
that  they  are  of  a  very  severe  type  and  intractable  to  treatment.  Anstie 
has  found  that  heredity  influences  the  development  of  neuralgia  in  the 
most  various  parts  of  the  body,  but  for  my  own  part,  I  have  only  found 
its  effects  distinctly  marked  in  affections  of  the  trigeminus  and  sciatic. 

The  predisposition  to  neuralgia  may  be  acquired  not  only  from  hered- 
ity but  also  during  the  developmental  period  of  youth,  from  overtaxing  of 
the  mental  powers.  Anstie  laid  great  stress  on  the  importance  of  this  fac- 
tor, especially  when  combined  with  a  false,  sentimental  religious  training. 
But  we  doubt  whether  this  element  is  as  prevalent  now,  even  in  England, 
as  it  was  ten  years  ago  (when  Anstie  wrote),  thanks  to  the  impetus  which 
has  been  given  of  late  years,  by  physicians  and  educators,  to  more  phy- 
siological methods  of  teaching.  In  our  own  country,  at  least,  we  know 
from  actual  observation  that  the  false,  forcing  plan  of  education  has  been 
done  away  with  in  considerable  part.  But,  although  great  reforms  are 
being  consummated  in  this  direction,  nevertheless  much  still  remains  to 
be  done,  which  requires  the  careful  and  thoughtful  consideration  of  our 
profession. 

Sex. — It  would  appear  from  the  experience  of  most  authors  that  the 
female  sex  presents  a  greater  tendency  to  the  development  of  neuralgic 
affections  than  the  male  sex.  Among  178  cases  which  came  under  my 
own  observation,  108  were  females  and  70  males.  I  have  not  included 
in  this  classification  those  cases  in  which  the  neuralgia  formed  part  of 


NEURALGIA.  99 

the  symptomatology  of  hysteria,  which  is  notoriously  much  more  com- 
mon among  females,  and  an  enumeration  of  which  would,  therefore,  in- 
crease the  above-mentioned  disproportion  to  a  still  greater  extent.  When 
we  come  to  examine  the  individual  varieties  of  neuralgia,  we  find  that 
the  female  sex  predominates  in  one  form,  and  the  male  in  another. 

Thus  among  ninety-five  cases  of  trigeminal  neuralgia,  seventy-one 
were  females,  and  only  twenty-four  males,  while  among  twenty-five  cases 
of  sciatica  there  were  eight  females  and  seventeen  males.  In  intercos- 
tal neuralgia  the  latter  relation  is  again  reversed,  and  the  large  majority 
of  cases  are  found  in  females.  In  the  articles  on  the  special  forms  of 
neuralgia  we  shall  enter  more  in  detail  into  these  various  considerations. 

A(/e. — An  analysis  of  my  cases  shows  that  from  the  tenth  to  the  twen- 
tieth years  of  life,  there  were  fourteen  cases;  from  the  twentieth  to  the 
thirtieth  years,  forty-eight  cases;  from  the  thirtieth  to  the  fortieth  years, 
forty-seven  cases;  from  the  fortieth  to  the  fiftieth  years,  thirty-four  cases; 
from  the  fiftieth  to  the  sixtieth  years,  nineteen  cases;  from  the  sixtieth 
to  the  seventieth  years,  tweh'e  cases;  and  from  the  seventieth  to  the 
eightieth  years,  four  cases.  We  therefore  find  that  the  first  ten  years  of 
childhood  present  no  tendency  toward  the  development  of  neuralgia. 
This  fact  is  also  demonstrated  by  an  analysis  of  543  cases  reported  by 
Valleix,  Eulenburg,  and  Erb,  among  which  number  there  were  only  three 
cases  below  the  age  of  ten  years. 

The  largest  number  occur  between  the  ages  of  twenty  and  forty  years, 
and  the  sexes  are  equally  represented  in  proportion  to  the  number  of 
neuralgics.  Our  statistics,  therefore,  run  counter  to  the  general  opinion 
that  the  largest  number  of  cases  of  the  disease  appear  in  women  before  the 
thirtieth  year.  They  also  serve  to  contradict  the  view  that  the  tendency 
to  neuralgia  disappears  almost  entirely  after  the  age  of  sixty.  From  the 
ages  of  sixty  to  eighty  years,  I  observed  sixteen  cases,  which,  when  com- 
pared with  the  number  in  other  bicennial  periods,  does  not  by  any  means 
show  a  diminution  in  the  neuralgic  tendency,  if  we  take  into  consider- 
ation the  smaller  number  of  individuals  at  such  an  advanced  age.  We 
should  also  remember  that  neuralgias  of  old  age  are  usually  the  most  in- 
tractable to  treatment,  and  they  are,  in  all  probability,  due  to  organic 
changes  in  the  central  nervous  structures,  brought  about  by  the  general 
decay  and  by  the  atheromatous  changes  so  frequently  observed  in  the 
arteries  at  this  period  of  life. 

Weather. — Not  only  do  patients,  as  a  rule,  suffer  most  in  damp  and 
windy  weather,  but  primary  attacks  are  also  apt  to  develop  under  such 
conditions.  This  is  not  true,  however,  of  all  varieties  of  neuralgia.  Thus 
it  is  not  often  observed  in  trigeminal  neuralgia,  compared  with  the  large 
number  of  cases  of  this  variety.  In  occipital  and  sciatic  neuralgias,  how- 
ever, this  is  a  very  frequent  mode  of  causation.  I  have  often  observed 
that  sciatica  is  not  uncommon  in  coach  drivers,  in  whom  the  constant 
sitting  position  and  the  exposure  to  inclement  weather  act  together  in 
producing  very  severe  forms  of  the  disease.  The  manner  in  which  these 
causes  act  in  producing  the  disease  (as  well  as  all  other  "  colds  "),  is  en- 
tirely unknown,  and  it  would  be  idle  and  unprofitable  to  enter  into  a 
discussion  of  the  various  theories  which  have  been  advanced  to  explain 
their  modus  oi^erandi,  since  all  are  insufficient,  and  are  based  on  more  or 
less  hypothetical  grounds. 

Sexual  system. — Great  stress  has  been  laid  by  some  authors  upon  the 
influence  of  the  period  of  puberty,  especially  in  girls,  when  connected  with 
deficient  or  painful  menstruation,  and  of  the  menopause,  in  producing 


100  FUNCTIONAL    NERVOUS    DISEASES. 

various  kinds  of  neuralgias.  But  we  cannot  agree  with  this  view.  Ner- 
vous disorders  not  infrequently  appear  at  these  periods,  but  they  do  not, 
except  in  comparatively  rare  cases,  assume  the  neuralgic  type. 

During  the  period  of  puberty  hysteria  is  apt  to  be  developed,  and 
neuralgia  not  infrequently  appears  as  one  of  the  symptoms  of  this  latter 
disease.  But  the  affection  then  presents  certain  characteristics  of  its 
hysterical  origin,  and  should  not  be  classed  among  true  neuralgias.  The 
menopause  is  also  liable  to  be  attended  with  a  peculiar  nervous  disorder, 
the  chief  characteristics  of  which  are  sudden  flashes  of  heat,  or  heat  fol- 
lowed by  cold,  which  usually  start  from  the  stomach  and  pass  up  the  chest 
or  to  the  back  ;  sudden  attacks  of  perspiration,  which  arise  without  any 
provocation  and  only  last  a  short  time;  dizziness;  not  infrequently, 
marked  increase  of  sexual  desire.  This  condition  is  sometimes  compli- 
cated by  a  serious  depression  of  spirits,  which  may  pass  into  melancholia, 
often  tinged  with  a  religious  element.'  But  we  have  very  rarely  had  rea- 
son to  attribute  an  attack  of  neuralgia  to  this  cause;  all  those  which  did 
appear  to  have  any  connection  with  the  menopause  were  cases  of  trigem- 
inal neuralgia. 

We  entertain  similar  views  with  regard  to  the  effects  of  excessive 
sexual  intercourse  or  masturbation.  While  these  factors  are  liable  to 
cause  a  condition  of  nervous  exhaustion  attended  with  vague  pains  in 
the  head  and  in  various  other  parts  of  the  body,  these  do  not  often  assume 
the  characteristics  which  we  have  described  in  the  chapter  on  the  clinical 
history  of  neuralgia. 

JDejoressed  general  health. — Under  this  heading  we  include  anaemia, 
arising  from  direct  loss  of  blood,  excessive  lactation,  long-continued  and 
exhausting  diarrhoea,  etc.,  and  the  cachexije,  caused  by  the  development 
of  carcinoma,  pulmonary  phthisis,  etc.  When  the  general  health  and 
vitality  are  lowered  by  any  of  these  causes,  neuralgia  finds  a  fertile  field 
for  its  production.  These  causes  appear  to  affect  chiefly  the  trigeminal 
and  intercostal  nerves,  and  the  etiological  relation  between  the  anaemia 
and  neuralgia  is  conclusively  shown  by  the  disappearance  of  the  latter  as 
soon  as  the  former  is  removed.  In  the  cachexise  developing  during  the 
course  of  incurable  diseases,  the  neuralgia  produced  is  apt  to  continue 
with  increasing  severity  until  death. 

Constitutional  diseases. — Syphilis  may  act  as  a  cause  of  neuralgia  in 
two  different  ways.  In  the  first  place,  it  may  produce  pressure  upon  the 
nerves  in  any  part  of  their  course,  either  from  thickening  of  the  bones  or 
periosteum,  or  the  development  of  gummy  tumors  in  adjacent  tissues,  or 
from  changes  in  the  nerves  themselves,  such  as  thickening  of  the  nerve 
sheaths,  hyperplasia  of  the  connective  tissue  between  the  nerve-fibres,  or 
gummv  infiltration  into  the  nerves.  The  effect  of  such  lesions  is  patent, 
and  neuralgias  due  to  them  may  affect  any  of  the  nerves  of  the  body  on 
account  of  the  irregularly  disseminated  character  of  these  lesions  in  the 
tertiary  stage  of  syphilis. 

It  appears,  however,  that  not  only  may  the  disease'  be  produced  by 
direct  syphilitic  lesions  of  nerves,  but  that  it  may  be  also  due  to  the  direct 
action  of  the  syphilitic  virus.     I  have  neither  been  able  to  find  any  men- 


'  We  may  here  remark  that  the  bromide  of  potassium,  in  thirty-grain  doses  t.i.d., 
acts  like  a  charm  in  the  majority  of  these  patients.  Whenever  the  melancholic  ten- 
dency is  present,  we  have  derived  considerable  benefit  from  the  inhalation  of  nitrite 
of  amyl,  gtt.  iij.  t.i.d.  After  a  while  this  dose  may  be  increased,  as  the  patients  aro 
apt  to  become  habituated  to  it. 


NEURALGIA.  101 

tion  made  of  this  circumstance  in  the  works  on  neurolofry  which  I  have 
consulted,  nor  have  I  met  with  any  cases  in  practice;  but  Fournier,  the 
distinguished  French  syphilog^rapher,  states  that  he  has  observed  cases 
of  supra-orbital  and  sciatic  neuralgia  during  secondary  syphilis,  and  in 
which  there  was  no  appreciable  lesion  of  the  nerves.  Tills  view  is  also 
advanced  by  Dr.  Keyes  in  his  recent  work  published  in  this  series.  He 
states  that  "  the  essential  influence  of  the  syphilitic  poison,  without  phys- 
ical lesion,  doubtless  occasions  some  nervous  symptoms,  especially  early 
in  the  disease,  such  as  neuralgias,  inordinate  appetite,  sciatica,  local  areas 
of  analgesia  and  anaesthesia  at  the  backs  of  the  hands,  and  elsewhere." 
A  knowledge  of  this  fact  is  of  course  important  with  regard  to  treat- 
ment. 

Blood-poisoning. — Blood-poisoning,  due  to  infection  with  pus,  etc., 
is  not  infrequently  attended,  if  the  patient  recovers  from  the  immediate 
effects  of  the  disease,  by  terrible  and  widely  diffused  neuralgias  which 
often  last  for  years.  The  disease  is  so  diffused  that  we  must  attribute  it 
to  the  poisonous  action  of  the  material  which  has  been  introduced  into 
the  blood  upon  the  sensory  portions  of  the  nerves  or  nerve-roots.  The 
distinguished  German  surgeon,  Pitha,  was  himself  a  sufferer  from  excru- 
ciating neuralgias  due  to  this  cause,  and  has  given  an  admirable  and 
graphic  account  of  his  disease, '  which  is  of  such  an  interesting  character 
that  we  shall  give  a  brief  abstract  of  it. 

Case  T. — "  In  the  early  acute  stage,  the  two  shoulder-joints  were  suc- 
cessively attacked  by  the  most  violent  boring  pains,  which,  after  lasting 
for  hours,  suddenly  and  completely  disappeared.  Hence  the  pain  darted 
off  to  the  pelvic  region,  affecting  the  bladder,  especially  its  neck,  and 
then  the  entire  urethra.  At  a  later  period  the  pain  was  confined  to  the 
neck  of  the  bladder,  simulating  perfectly  all  the  symptoms  of  stone.  I 
felt  with  the  utmost  distinctness  the  spicula  at  the  surface  of  the  calculus 
being  forced,  during  the  paroxysm,  into  the  orifice  of  the  bladder.  Grad- 
ually I  lost  this  sensation  completely,  and  it  only  accidentally  appeared 
again  in  a  milder  degree  at  the  end  of  two  years.  While  jumping  over  a 
ditch  I  suddenly  experienced  the  sensation  of  a  stone  in  the  bladder  strik- 
ing against  the  symphisis.  So  plainly  did  the  existence  of  the  stone 
seem  on  various  occasions,  that  all  the  preparations  were  made  for  litho- 
tripsy, but,  to  my  great  astonishment,  the  most  careful  exploration  of  the 
bladder,  repeated  five  times,  failed  to  discover  the  calculus,  and  I  became 
convinced  at  last  that  it  did  not  exist.  The  most  severe  neuralgia  which 
I  at  present  suffer  from  affects  the  heel;  and  the  pain  at  its  greatest  se- 
verity takes  on  exactly  the  form  as  if  the  periosteum  were  being  separated 

from  the  os  calcis Omalgia,  cystodynia,  proctalgia,  and 

neuralgia  intercostalis,  ulnaris,  ischiadica,  peronea,  cruralis,  and  digito- 
rum  manus  et  pedis,  tortured  me  one  after  another,  and  often  several 
simultaneously,  sometimes  only  for  a  short  time,  and  at  others  for  days 
together,  producing  an  amount  of  suffering  that  was  difficult  to  endure." 

Malaria. — In  malarial  districts  this  constitutes  one  of  the  most  im- 
portant factors  in  the  etiology  of  neuralgia.  Even  in  our  own  city  it 
forms  a  considerable  contingent  in  the  latter  affection.  In  the  majority 
of  cases  it  affects  the  supra-orbital  branch  of  the  trigeminus  (popularly 
known  as  brow-ague),  and  the  paroxysm  of  pain  appears  instead  of   the 

1  Med.  Times  and  Gazette,  1875,  ii.,  p.  356. 


102  FUNCTIONAL    NERVOUS   DISEASES. 

fall-blown  malarial  attack.  Other  nerves  are  much  more  rarely  affected, 
tliough  there  is  hardly  a  sensory  nerve  in  the  body  which  may  not  be- 
come involved.  Next  to  the  trigeminus,  the  sciatic  nerve  is  most  fre- 
quently the  seat  of  pain,  and  then  follow  the  other  nerves  without  any 
distinct  preference.  As  we  have  stated  in  the  chapter  on  clinical  histor}', 
even  neuralgias  which  are  undoubtedly  due  to  organic  affections  of  the 
nerves,  may  run  a  distinctly  periodical  course,  so  that  this  feature  is  not 
pathognomonic  of  the  malarial  character  of  the  affection.  We  are  not 
justified  in  attributing  an  attack  of  neuralgia  to  malaria,  unless  we  find 
upon  inquiry  that  the  patient  has  been  subject  to  malarial  influences,  or 
can  detect  an  enlargement  of  the  spleen  upon  physical  examination.^ 

Mhewnatism,  etc. — The  loose  manner  in  which  this  term  has  been  em- 
ployed in  medical  literature,  has  been  the  cause  of  a  great  deal  of  confu- 
sion. The  laity  frequently  use  the  terms  neuralgia  and  rheumatism  inter- 
changeably, and  so-called  rheumatic  influences  are  regarded  as  frequent 
causes  of  the  former  affection.  But  rheumatism,  in  the  strict  seTise  of 
that  term,  is  very  rarely  the  cause  of  neuralgia,  and,  in  these  rare  cases, 
it  appears  that  the  sciatic  nerve  is  always  the  one  involved.  In  former 
times  gout  was  also  regarded  as  a  frequent  cause  of  neuralgia,  but  the 
simple  gouty  diathesis  does  not  often  act  in  this  manner.  Whenever 
neuralgia  develops  in  gouty  patients  in  consequence  of  the  latter  process,  ifc 
is  almost  always  due,  as  Anstie  has  pointed  out,  either  to  the  malnutrition, 
of  the  nervous  system  induced  by  the  changes  in  the  blood-vessels,  or  to 
the  pressure  of  gouty  deposits  in  the  joints,  tendons,  etc.,  upon  adjacent 
nerves. 

Neuralgias  may  also  develop  during  convalescence  from  small-pox, 
scarlatina,  rubeola  and  typhoid  fever,  but  it  is  very  probable  that  in  these 
cases  the  disease  is  similar  to  the  other  nervous  disturbances,  such  as  peri- 
pheral paralysis,  circumscribed  atrophy  of  muscles,  etc.,  which  are  ob- 
served from  time  to  time  after  these  infectious  diseases.  Nothnagel  has 
also  called  attention  to  the  development  of  well-marked  neuralgia  in  the 
first  stages  of  typhoid  fever.  This  must  not  be  confounded  with  the 
cutaneous  hyperresthesia  {which  is  sometimes  extremely  acute)  not  un- 
commonly observed  in  the  first  week  or  two  of  the  disease,  and  which  is 
entirely  distinct  from  neuralgia. 

Lead,  mercurial,  and  arsenic  poisoning  are  also  regarded  as  causes  of 
this  disease,  but  the  pains  to  which  these  affections  give  rise,  though  they 
are  sudden  and  shooting  in  character,  are  situated  chiefly  in  the  muscles,  and 
are  not  confined  to  the  district  of  a  single  nerve.  We  are  hardly  justified, 
therefore,  in  considering  them  as  evidences  of  true  neuralgia. 

We  have  a  case  under  observation  at  present  in  which  wandering 
neuralgic  pains  developed  in  the  lower  limbs  as  a  sequel  of  acute  arsenical 
poisoning.  These  were  soon  followed,  however,  by  atrophy  and  paralysis 
of  the  limbs,  some  loss  of  sensation,  and  paralysis  of  the  bladder.  The 
symptoms  are  probably  due  to  subacute  transverse  myelitis,  and  the  neu- 
ralgic pains  were  merely  a  part  symptom  of  this  affection. 

Alcohol  and  tobacco. — The  excessive  use  of  these  substances  is  also 
productive  of  bad  results  in  this  direction,  not   so  much   as  an  effect  of 

'  We  wish  to  call  attention  to  the  fact  that  the  opinion  laid  down  in  some  of  the 
text-books,  with  regard  to  the  position  of  the  spleen,  is  erroneous,  and  that  the  org'an 
does  not  normally  extend  forward  beyond  the  middle  of  the  axillary  space.  This 
was  first  pointed  out  to  me  several  years  ago  by  my  friend  Dr.  Janeway,  and  I  have 
since  then  frequently  verified  his  opinion  by  observations  upon  the  cadaver. 


NEURALGIA.  103 

acute  intoxication,  but  rather  of  their  long-continued  introduction  into 
the  system.  The  immoderate  use  of  tobacco  sometimes  gives  rise  to  attacks 
of  angina  pectoris,  which  is  undoubtedly  a  true  neuralgia,  but  a  consid- 
eration of  which  is  beyond  our  province  at  the  present  time,  since  we  are 
onlv  discussing  neuralgias  of  the  superficial  nerves.  Aside  from  this  form 
tobacco  is  very  rarely  a  cause  of  the  affection. 

Alcohol  in  very  rare  cases  may  produce  neuralgia  as  a  result  of  acute 
intoxication.  Thus,  I  have  seen  three  cases  of  sciatica  due  to  acute 
alcoholism.  As  a  rule,  however,  alcoholism  produces  these  effects  as  the 
result  of  long-continued  drinking,  in  consequence  of  changes  in  the 
blood-vessels,  etc.  The  headaches  to  which  drinkers  are  so  frequently 
subject  cannot  be  classed,  however,  under  the  category  of  true  neuralgias. 
They  are  due  to  cerebral  pachymeningitis  (which  is  very  often  observed 
in  drunkards)  to  congestion  of  the  brain,  to  Bright's  disease  (cirrhotic  or 
*'  whiskey  "  kidney),  gastric  catarrh,  etc. 


Local  Causes. 

The  term  local  causes  refers  to  those  which  act  directly  upon  the 
nerves,  either  at  their  origin  in  the  cerebral  or  spinal  centres,  during  their 
course  to  the  periphery,  or  perhaps  even  at  the  peripheral  terminations. 
"Within  the  cranial  cavity  this  category  includes  tumors  at  the  base  of 
the  brain  which  press  directly  upon  the  Gasserian  ganglion,  periostitis  of 
the  petrous  portion  of  the  temporal  bones,  aneurism  of  the  internal  caro- 
tid. In  the  spinal  canal,  it  comprises  tumors  of  the  cords,  localized  men- 
ingitis, pachymeningitis,  and  peripachymeningitis,  spondylitis  deformans, 
caries  and  cancer  of  the  vertebrce,  the  pressure  from  aneurisms  of  the 
aorta. 

During  the  course  of  the  nerves,  neuralgia  may  be  produced  by  pres- 
sure from  without,  such  as  from  aneurismal  dilatation  of  adjacent  vessels, 
enlarged  cheesy  or  calcareous  glands,  various  neoplasms,  the  pressure  of 
the  intestine  (herniie  into  the  sciatic  and  obdurator  foramina),  or  its  con- 
tents, pressure  of  dilated  venous  plexuses,  periosteal  thickenings  (either 
of  bones  across  which  the  nerves  pass,  or  of  bony  canals  which  they 
traverse).  Neuralgia  may  also  be  due  to  lesions  of  the  nerves  themselves, 
such  as  those  produced  by  injury,  idiopathic  neuritis,  or  the  development 
of  tumors  in  the  nerves  (neuromata,  pseudo-neuromata,  gliomata,  etc.). 
We  shall  refer  to  these  special  causes  more  in  detail  when  we  describe 
the  individual  varieties  of  the  disease. 


Reflex  Causes. 

By  reflex  neuralgias  we  mean  those  in  which  the  cause  is  situated  with- 
in the  distribution  of  a  nerve  other  than  that  which  is  the  site  of  the  neu- 
ralgic pain.  One  of  the  most  important  factors  in  this  category  is  func- 
tional disturbance  of  the  organs  of  sight.  Dr.  George  T.  Stevens  (JTedi- 
cal  Record,  October  13,  1877),  has  advanced  the  following  propositions  in 
this  connection  : 

1.  Among  centripetal  influences  which  generate  neuralgia,  the  irrita- 
bility arising  from  a  perplexity  or  exhaustion  of  nerves  engaged  in  the 
function  of  accommodation  of  the  eye,  must  be  regarded  as  by  far  the 
most  frequent  and  important. 


104  FUNCTIONAL    NERVOUS    DISEASES. 

2.  Many  inveterate  cases  of  chronic  neuralgia  not  amenable  to  other 
forms  of  treatment,  readily  yield  to  the  simple  process  of  relieving  the 
eye  from  irritation  resulting  from  direct  accommodation. 

These  views  are  confirmatory  of  the  statements  of  Anstie,  who  also 
lays  great  stress  upon  the  efficacy  of  eye  troubles  in  the  production 
of  neuralgia.  But  these  opinions  appear  to  us  to  be  exaggerated.  In 
our  own  experience,  at  least,  this  cause  has  only  been  operative  in  a  small 
number  of  cases,  producing  in  the  large  majority  of  individuals  other  symp- 
toms, such  as  dull  headache,  inability  on  the  part  of  the  patient  to  apply 
himself  steadily  to  any  mental  work,  a  general  tired  feeling,  and  some- 
times considerable  dizziness,  etc. 

Caries  of  the  teeth  is  a  frequent  source  of  neuralgia,  especially  in  the 
branches  of  the  trigeminus.  But  Anstie  mentions  a  peculiar  and  inter- 
esting case  in  which  uterine  neuralgia  was  immediately  relieved  by  the 
removal  of  a  carious  tooth.  Salter  has  also  called  attention  to  the  com- 
parative frequency  of  cervico-brachial  neuralgias  which  are  due  to  this 
cause. 

Foreign  bodies  in  the  various  cavities  of  the  head  may  also  give  rise 
to  eccentric  neuralgias,  and,  in  one  instance,  a  neuralgia  of  twelve  years 
standing  was  relieved  permanently  after  the  removal  of  a  foreign  body 
from  the  cheek. 

Reflex  neuralgias  may  develop  from  various  functional  or  organic  dis- 
orders of  the  intestinal  tract. 

The  genito-urinary  system,  both  in  the  male  and  female,  also  figure 
not  infrequently  among  the  causes  of  the  disease.  This  is  especially 
true  of  uterine  disorders,  to  which  are  attributed  numerous  neuralgias, 
especially  those  of  the  lower  limbs.  The  following  interesting  case, 
reported  by  Hunt,'  is  one  in  which  there  can  be  no  doubt  of  the  reflex 
origm  of  the  neuralgic  affection.  "  The  patient  began  to  suffer  from 
severe  neuralgic  pains  along  the  course  of  the  trigeminus  during  the 
seventh  month  of  pregnancy.  Premature  delivery  began  during  the 
second  night  after  the  beginning  of  the  neuralgia  ;  the  pain  attained  its 
maximum  during  parturition,  but  ceased  after  its  completion.  When  the 
hand  was  introduced  into  the  uterus  in  order  to  remove  the  placenta,  the 
pain  returned  with  great  severity,  and  lasted  while  it  was  being  removed. 
It  vanished  immediately  after  this  was  done." 

Mauriac  ^  has  called  attention  to  the  comparative  frequency  of  reflex 
neuralgias  in  various  parts  of  the  body,  during  the  course  of  gonorrhoeal 
orchi-epididymitis. 

In  addition  to  cases  in  which  the  irritation  is  situated  in  the  viscera, 
others  are  reported  in  which  injury  in  the  course  of  one  nerve  has  pro- 
duced neuralgia  in  the  distribution  of  another.  Such  cases  are  extremely 
rare,  and  we  have  only  found  records  of  them  as  occurring  in  the  trigem- 
inus, occipital,  and  brachial  nerves.  Thus,  an  injury  to  the  ulnar  nerve 
has  been  known  to  produce  trigeminal  neuralgia. 

'  On  the  Nature  and  Treatnaent  of  Tic  Douloureux,  Sciatica,  and  other  Neuralgic 
Disorders,  London,  1844,  p.  99. 
'  Gaz.  med.  de  Paris,  Dec,  1878. 


CHAPTER  III. 

PATHOLOGY. 

As  in  all  the  other  functional  neuroses,  this  field  of  investigation  is 
extremely  unsatisfactory.  The  pathological  anatomy  of  neuralgia  has 
been  the  subject  of  laborious  investigation,  but  the  results  are  very  mea- 
gre. In  a  considerable  proportion  of  the  cases  in  which  it  was  possible 
to  examine  the  condition  of  the  affected  nerves,  either  post-mortem  or 
after  the  operation  of  neurectomy,  no  anatomical  lesions  were  discover- 
ed. Billroth  states  that  he  has  so  frequently  obtained  negative  results, 
that  "  he  has  become  tired  of  making  the  examination."  At  other  times 
various  macroscopic  and  microscopic  lesions  are  found,  not  alone  in  the 
nerve-tissues  themselves,  but  also  in  the  surrounding  structures.  The 
following  are  the  lesions  which  have  been  observed:  congestion  and  thick- 
ening of  the  sheath  of  the  nerve;  sclerotic  changes  and  atrophy  of  the 
nerve  itself;  neuromata,  true  and  false;  tumors  growing  from  the  sur- 
rounding tissues  and  pressing  upon  the  nerves;  simple  atrophy  of  the 
nerves;  capillary  hemorrhages  into  their  substance;  granular  degenera- 
tion of  the  axis  cylinders;  hypertrophy  of  some  of  the  fibres,  and  atrophy 
of  others;  inflammation  of  the  ganglia  on  the  roots  of  the  nerves;  calca- 
reous degeneration  of  these  ganglia;  atrophy  from  pressure  of  exostoses, 
tumors,  retracting  inflammatory  processes,  etc.,  etc. 

It  is  very  evident,  however,  from  the  negative  character  of  the  exam- 
ination in  so  many  cases,  and  from  the  multiplicity  of  the  lesions  which 
have  been  observed  in  others,  that  there  are  no  anatomical  characters  pe- 
culiar to  neuralgia.  It  is  even  doubtful  whether  many  of  these  lesions 
are  not  of  a  secondary  nature,  caused  by  the  often  repeated  vascular  dis- 
turbance in  the  nerves  (occurring  in  the  paroxysm  of  pain),  and  by  the 
trophic  changes  so  frequent  in  this  disease. 

The  site  of  the  affection  has  been  variously  located  by  different  writers, 
but  the  most  plausible  theory  is  that  advocated  with  great  enthusiasm  by 
xA.nstie,  who  believes  that  the  morbid  process  is  situated  in  the  posterior 
roots  of  the  nerves,  or  in  the  gray  matter  immediately  connected  with 
them. 

This  observer  believes  that  "the  morbid  change  in  the  nerve-centre  is 
probably,  in  the  vast  majority  of  cases,  an  interstitial  atrophy,  tending 
either  to  recovery,  or  to  the  gradual  establishment  of  gray  degeneration, 
or  yellow  atrophy,  of  considerable  portions  or  the  whole  of  the  posterior 
root,  and  the  commencement  of  the  sensory  trunk  as  far  as  the  ganglion." 
The  great  objection  to  his  views  is  that  these  lesions  have  never  been 
found  in  neuralgia,  although  frequent  examinations  have  been  made  in 
the  hope  of  discovering  them.  But  although  this  is  true,  Anstie  never- 
theless adduces  weighty  reasons  for  locating  the  disease  in  this  situa- 
tion, and  it  may  very  well  be  that  his  views  are  correct,  in  this  respect, 
although  the  lesion  is  perhaps  of  a  molecular  or  chemical  nature.     Among 


106  FUNCTIONAL    NEEVOUS    DISEASES. 

the  arsruments  which  he  has  brousrht  forward  to  show  the  central  nature 
of  neuralgia  are: 

1.  The  disease  is  undoubtedly  an  hereditary  neurosis  in  numerous 
instances,  and,  as  such,  must  be  due  to  some  changes  in  the  central 
nervous  system. 

2.  There  are  certain  organic  diseases  of  the  spinal  cord,  notably  loco- 
motor ataxia,  in  which  neuralgic  pains  play  an  important  part  in  the 
symptomatology.  In  addition,  it  must  be  remembered  that  locomotor 
ataxia  is  a  disease  of  the  posterior  columns  of  the  spinal  cord,  and  that, 
in  some  cases,  some  of  the  fibres  of  the  posterior  roots  of  the  nerves  have 
been  found  implicated  in  the  sclerotic  changes.  Even  in  cases  in  which 
the  posterior  nerve-roots  present  no  anatomical  lesions,  it  is  probable  that 
they  are  in  a  condition  of  irritation. 

3.  The  peripheral  irritation  of  a  particular  sensory  nerve  ma}'^  produce 
neuralgia  in  nerves  which  are  connected  with  the  irritated  one  only 
through  the  spinal  centre.  This  is  incontrovertible  proof  that  some  dis- 
turbance must  have  been  transmitted  through  the  sensory  portions  of  the 
cord,  as  such  a  reflex  transmission  is  explicable  in  no  other  manner.  The 
secondary  implication  of  the  spinal  cord  after  lesions  of  the  peripheral 
nerves,  is  admitted  also  in  the  theory  of  neuritis  migrans,  and  Anstie 
states  that,  although  the  lesion  of  the  posterior  nerve-roots  in  neuralgia 
is  usually  non-inflammatory  in  its  origin,  nevertheless,  in  rare  instances,  it 
may  consist  of  a  localized  centripetal  myelitis,  secondary  to  inflammation, 
of  the  primarily  affected  nerve. 

4.  Unless  the  neuralgia  is  very  slight  and  of  short  duration,  it  is  gen- 
erally accompanied  by  vaso-motor  spasm,  secretory,  sensory,  motor,  and 
trophic  disorders.  This  combination  of  symptoms  is  also  most  readily 
explained  by  a  lesion  situated  in  the  position  claimed  by  Anstie. 

There  are  some  cases,  however,  to  which  this  theory  will  not  by  any 
means  apply.  How,  for  instance,  can  we  accept  the  doctrine  of  a  central 
lesion  in  a  case  in  which  a  trigeminal  neuralgia,  which  had  lasted  for 
twelve  years,  was  immediately  and  permanently  removed  by  the  removal 
of  a  foreign  body  from  the  cheek? 

Then  again  there  are  numerous  other  instances  in  which  neuritis  or 
injuries  to  nerves  near  their  periphery,  etc,  give  rise  to  neuralgia,  and  in 
these  cases  likewise  it  is  more  plausible  to  assume  a  peripheral  origin  of 
the  neuralgic  affection. 

But,  in  spite  of  all  the  objections  which  may  be  advanced  against 
Anstie's  theory,  it  is  the  one  which  is  capable  of  explaining  the  majority 
of  phenomena  observed  in  the  course  of  neuralgia,  especially  in  those  in 
which  heredity  is  a  prominent  etiological  factor,  or  in  which  the  affection 
is  due  to  a  constitutional  cause. 

Uspensky  *  has  propounded  a  theory  of  neuralgia,  based  on  physiolo- 
gical considerations,  which  is  analogous  to  that  arrived  at  by  Anstie  as 
the  result  of  his  profound  investigations  into  the  clinical  history  of  the 
disease.  Schiff,  Heidenhain,  and  Ranke  had  shown  that  irritation  of  the 
nerves  produces  a  rise  of  temperature  and  changes  the  normal  alkaline 
reaction  of  the  nervous  tissues  to  a  neutral  reaction  in  the  nerves  and  an 
acid  reaction  in  the  nerve-centres  (on  account  of  the  formation  of  lactic 
acid  and  the  acid  phosphate  of  soda).  These  products  of  disassimilation 
irritate  the  nervous  system,  and  Uspensky  considers  himself  justified  in 
the  opinion  "  that  every  pain  is  either  produced,  or  at  least  accompanied, 

'  Deutsch.  Arch.  f.  Klin.  Med.  1876. 


NEURALGIA.  107 

by  the  formation  of  a  certain  quantity  of  these  products  of  disassimila- 
tion  in  the  nerve-tissues,  and  by  their  effect  upon  the  nervous  system." 

He  sums  up  his  theory  in  tlie  following  words:  "  Under  the  influence 
of  a  constant  but  weak  irritation  of  the  peripheral  nerves,  the  sensory 
nerve-cells  of  the  posterior  horns  of  the  spinal  cord  are  continually  called 
into  action,  and  produce,  as  a  reflex  effect,  a  peristaltic  contraction  of  the 
vessels,  which  leads  to  the  absorption  of  the  products  of  nervous  energy. 
In  the  course  of  time  the  absorption  diminishes  on  account  of  previous 
increased  activity,  and  the  products  which  irritate  the  nervous  tissues 
then  begin  to  accumulate.  When  they  have  reached  a  certain  amount 
they  first  produce,  on  account  of  the  irritation  of  the  sensory  nerve-cells, 
tetanic  contraction  of  the  vessels,  and  then  paralytic  dilatation.  Repeated 
recurrence  of  the  circulatory  disturbance  may  lead  to  atrophy  of  the  sen- 
sory nerve-cells,  and  cause  a  change  in  the  calibre  of  the  vessels,  with  loss 
of  their  tonus." 

While  this  theory  is  very  ingenious  and  the  conclusions  at  which 
Uspensky  arrives  with  regard  to  the  localization  of  the  lesion  agree,  in 
the  main,  with  those  reached  by  Anstie,  nevertheless  his  argument  is 
based  on  purely  hypothetical  grounds,  and  some  of  his  premises  are  more 
than  problematical. 

Beiiedikt,  finally,  also  holds  somewhat  similar  views,  maintaining  that 
a  considerable  number  of  ne^iralgias  are  due  to  neuritis  of  the  primarily 
affected  nerve,  which,  spreading  upward  along  the  nerves,  may  finally 
lead  to  atrophy  of  the  posterior  horns.  He  also  believes  that  the  changes 
at  the  bottom  of  neuralgia  may  be  primarily  situated  in  the  spinal  cord, 
and  be  due  to  circulatory  disturbances  in  the  posterior  horns,  or  to  slight 
meningeal  inflammations  at  the  posterior  part  of  the  cord.  The  great 
objection  to  this  view,  as  to  the  others  mentioned  above,  is  that,  on  the 
one  hand,  these  lesions  are  not  always  present  in  neuralgia,  and  that,  on 
the  other,  they  may  be  present,  although  neuralgia  is  absent. 

We  are  of  the  opinion  that  while  Anstie's  theory  probably  holds  good 
with  regard  to  a  considerable  number  of  neuralgias,  notably  those  which 
are  due  to  hereditary  influences  or  to  constitutional  diseases,  nevertheless 
it  is  far  from  being  conclusively  proven.  We  can  therefore  only  accept 
it  as  a  good  "  working  theory." 

The  causation  of  the  puncta  dolorosa  is  another  stumbling-block.  The 
usually  accepted  theory  has  been  that  the  painful  point  is  the  site  of  a 
localized  neuritis,  or  at  least  of  congestion,  and  that  these  lesions  account 
for  the  production  of  pain.  We  must  remember,  however,  that  even  if 
such  a  local  lesion  of  the  nerves  were  demonstrated  (which  it  is  not),  the 
pain  on  pressure  should  be  felt  at  the  peripheral  distribution  of  the 
nerves,  in  the  same  manner  that  a  blow  upon  the  "funny  bone  "  produces 
a  sensation  of  tingling  in  the  little  and  ring  fingers. 

According  to  Sandras,  the  puncta  dolorosa  do  not  depend  on  the  condi- 
tion of  the  nerves,  but  rather  on  that  of  the  adjacent  tissues,  Avhich  ren- 
der the  spots  more  capable  of  being  pressed  upon.  The  same  objections 
may  be  urged  against  this  as  against  the  former  view. 

According  to  a  very  plausible  theory,  the  painful  spots  are  explained 
by  the  presence  in  the  affected  nerve  of  the  recurrent  sensory  fibres  de- 
monstrated by  Arloing  and  Tripier.  It  is  supposed  that  these  fibres  ter- 
minate in  that  portion  of  the  nerve  corresponding  to  the  painful  spot,  and 
that  pressure  upon  the  latter  will  therefore  give  rise  to  pain  in  the  part 
pressed  upon.  The  only  objection  to  this  theory  is  that  proof  is  still 
wanting  that  the  recurrent  fibres  do  terminate  in  the  spots  referred  to. 


CHAPTER  ly. 

DIAGNOSIS  AND  PROGNOSIS. 

Although  the  term  neuralgia  has  been  very  loosely  applied  to  the 
most  various  kinds  of  painful  affections,  nevertheless  the  disease,  although 
symptomatic  of  numerous  underlying  processes,  is  very  clearly  defined, 
and,  as  a  rule,  readily  recognizable. 

As  we  have  seen  in  the  chapter  on  clinical  history,  neuralgia  pre- 
sents the  following  characteristics: 

1.  The  pain  is  always  paroxysmal,  at  least  in  the  beginning,  and 
exacerbations  are  manifested  even  after  the  disease  has  lasted  for 
years. 

2.  The  paroxysm  usually  begins  suddenly,  the  pain  is  shooting,  dart- 
ing, lancinating,  boring,  etc.,  and  is  referred  along  the  course  of  the 
nerves. 

3.  The  paroxysm  develops  spontaneously,  or  in  consequence  of  some 
trifling  cause  not  at  all  commensurate  with  the  severity  of  the  pain  pro- 
duced. 

4.  In  perhaps  the  majority  of  cases,  puncta  dolorosa  are  observed  iu 
some  portion  of  the  course  of  the  nerves. 

5.  Vaso-motor,  secretory,  or  trophic  disorders  are  noticed  in  a  consid- 
erable proportion  of  cases. 

There  are,  of  course,  other  symptoms  which  are  corroborative,  but  the 
first  three  are  essential  to  the  diagnosis  of  neuralgia. 

A  considerable  number  of  other  painful  diseases  may  be  mistaken  for 
neuralgia,  and  perhaps  the  most  frequent  one  is  myalgia,  or  so-called 
muscular  rheumatism.  This  affection  is  sometimes  supposed  to  be 
closely  related  to  true  rheumatism,  but  such  a  view  is  entirely  errone- 
ous. The  disease  is  located,  not  in  the  joints  or  fibrous  tissues,  as 
in  articular  rheumatism,  but  in  the  muscular  or  terminal  filaments  of  the 
nerves. 

As  in  severe  neuralgias,  the  part  affected  is  kept  immovable  in 
order  to  prevent  a  fresh  attack  of  pain,  but,  unlike  neuralgia,  the  parts 
may  be  subjected  to  passive  motion  without  increased  suffering.  In 
myalgia,  in  other  words,  the  pain  develops  on  active  contraction  of 
the  muscles,  and  not  from  passive  contraction  or  mere  motion  of  the 
parts. 

The  pain  of  myalgia,  also,  is  diffused  over  the  entire  surface  of  the 
affected  muscles,  and  is  not  confined  to  the  course  of  any  special  nerves; 
it  is  dull  and  steady,  not  sharp  and  paroxysmal  as  in  neuralgia.  Further- 
more, myalgia  is  never  accompanied  by  puncta  dolorosa;  the  whole  mus- 
cle is  tender  to  pressure,  and  this  is  especially  marked  at  its  origin  and 
insertion,  Avhere  its  structure  becomes  tendinous.  Finally,  a  very  char- 
acteristic difference  between  the  two  diseases  is  found  in  the  different 
effects  of  the  faradic  current.     True   neuralgia  is  usually  rendered  worse 


NEURALGIA.  109 

by  a  strong  current  of  faradism,  while  myalgia  is  always  relieved  by  it, 
and  sometimes  cured  as  if  by  magic' 

Osteocopic  pains  of  syphilis  are  also  often  mistaken  for  neuralgia. 
They  usually  occur  in  the  secondary  stage,  and  instead  of  being  of  a 
lancinating  character,  and  running  along  the  course  of  the  nerves,  as  in 
true  neuralgia,  they  are  of  a. boring  character,  and  confined  to  a  cir- 
cumscribed spot  upon  the  surface  of  the  bones.  As  a  rule,  to  which 
there  are  very  few  exceptions,  they  present  very  marked  exacerbations 
at  ni"-ht.  Another  differential  diagnostic  point  is  furnished  by  the  re- 
sults of  treatment,  since  mercury  usually  produces  excellent  results  in 
osteocopic  pains,  and  would  probably  only  exaggerate  the  symptoms  in 
cases  of  neuralgia. 

In  the  condition  commonly  known  as  cerebral  ancemia  (but  which 
is  only  a  form  of  ordinary,  general  anaemia),  pains  in  the  head  are 
almost  always  observed,  and  are  very  frequently  mistaken  for  neuralgia. 
They  present,  however,  very  marked  differences.  The  pains  of  anremia 
are  usually  diffused  over  the  entire  vertex,  are  attended  with  a  sensa- 
tion of  heat,  and,  instead  of  being  paroxysmal,  are  continuous,  dull,  and 
of  a  peculiar  lifting  character  (they  are  sometimes  likened  to  a  pot  of 
boiling  water).  The  entire  scalp  may  be  excessively  tender  on  pressure, 
but  there  are  no  true  puncta  dolorosa.  In  addition,  the  patients  usually 
suffer  from  insomnia  (although  they  complain  of  drowsiness  during  the 
day),  from  palpitation  of  the  heart,  shortness  of  breath  on  exercise, 
and  all  the  other  well-known  signs  of  anremia.  The  conjunctivas  will 
usually  be  found  paler  than  normal,  although  the  patients  not  infrequent- 
ly present  a  good  complexion. 

In  certain  cases  neuralgia  may  be  mistaken  for  neuritis,  and,  in  the 
minds  of  a  great  many,  these  are  convertible  terms.  As  we  have  repeat- 
edly shown,  the- most  intense  neuralgia  may  develop,  although  the  affected 
nerve  is  entirely  normal  (this  is  rendered  most  evident  when  we  remem- 
ber that  neuralgia  may  develop  as  the  result  of  an  affection  of  an  entirely 
different  part  of  the  body  from  that  which  is  the  seat  of  the  pain),  and,  on 
the  contrary,  neuritis  may  be  well  marked  without  the  development  of 
neuralgia.  Nevertheless,  it  is  sometimes  very  difficult,  or  even  impossi- 
ble, to  differentiate  these  affections,  and  the  two  conditions  may  even  be 
combined.  In  neuritis,  the  pain  is  usually  continuous,  though  it  some- 
times presents  remissions,  the  entire  course  of  the  affected  nerve  is  tender 
(when  superficial,  it  is  sometimes  distinctly  swollen),  and  there  are  no 
puncta  dolorosa;  motor  paralysis  and  localized  atrophy  of  muscles  soon 
become  evident  in  severe  cases.  We  must  confess,  however,  that  some 
of  these  differential  symptoms  may  be  absent,  and  we  may  therefore  be 
unable  to  determine  the  exact  nature  of  the  malady  with  which  we  have 
to  deal. 

As  a  rule,  spinal  irritation  is  readily  distinguished  from  true  neural- 
gia. The  most  marked  differential  point  is  the  wandering  character  of 
the  pains  in  the  former  aft'ection.  Spinal  tenderness  is  a  prominent 
symptom,  and  the  tender  spinous  processes  correspond  somewhat  to 
Trousseau's  pohits  a2:>oph]/salres.  They  differ,  however,  in  the  fact  that 
they  are  apt  to  vary  their  location  from  time  to  time.     Cutaneous  hy- 

'  One  patient  who  had  very  severe  myalgia  of  the  back  of  the  neck  and  shoulders, 
and  who  had  been  thereby  incapacitated  from  work  for  two  months,  was  entirely  cured 
after  one  application  (ten  minutes'  duration)  of  as  strong  a  primary  faradic  current  aa 
he  could  bear ;   many  similar  cases  have  come  under  my  observation. 


110  FUNCTIONAL   NERVOUS   DISEASES. 

peraesthesia  and  various  other  hysterical  symptoms  are  combined  with 
the  spinal  tenderness.  In  some  cases,  however,  a  true  neuralgia  may 
lead  to  the  development  of  spinal  irritation,  and  the  two  affections  are 
not  infrequently  combined  in  young  females. 

Finally,  we  will  consider  the  differences  between  neuralgia  and  the 
pains  of  locomotor  ataxia.  We  must  remember  that  pains  may  for  years 
constitute  almost  the  sole  symptom  of  tabes  dorsalis,  and  they  are, 
therefore,  frequently  mistaken  in  the  first  stage  for  ordinary  neuralgia, 
thus  leading  to  grave  errors  both  as  regards  prognosis  and  treatment. 
In  ataxia,  however,  the  pains  are  situated  in  both  lower  limbs:  they  are 
described  as  being  situated  sometimes  in  the  muscles,  sometimes  along 
the  course  of  the  nerves,  they  are  more  irregular  in  their  appearance  than 
true  neuralgic  pains,  they  rapidly  move  from  one  portion  of  the  limbs  to 
another,  and  are  not  accompanied  by  vaso-motor  or  trophic  disorders. 
Even  in  this  early  stage,  the  patellar  tendon  reflex  is  generally  absent. 
But,  in  the  majority  of  cases,  other  characteristic  symptoms  are  also 
present,  such  as  contraction  of  the  pupils,  diplopia,  atrophy  of  the  optic 
disc,  the  cincture  feeling,  disturbances  of  the  bladder  and  of  the  sexual 
function,  anaesthesia  of  the  lower  limbs,  notably  of  the  soles  of  the  feet, 
and  inco-ordination  of  movement. 

But  not  alone  is  it  important  to  differentiate  neuralgia  from  other 
painful  affections,  we  must  also  endeavor  to  determine  whether  the  peri- 
pheral nerves  or  the  central  nervous  system  is  involved.  A  careful  inves- 
tigation of  the  etiology  of  the  case  is  often  of  great  importance  in 
arriving  at  a  conclusion  in  this  respect.  Thus,  for  instance,  if  one  of  the 
peripheral  nerves  has  been  subjected  to  a  trauma,  and  a  neuralgia  devel- 
ops which  is  strictly  confined  to  the  distribution  of  such  nerve,  we  are 
perfectly  justified  in  believing  that  the  lesion  which  has  given  rise  to  the 
neuralgia  is  situated  at  the  injured  part  of  the  nerve.  But  it  is  only  in 
a  few  cases  that  we  can  form  an  opinion  so  readily  and  satisfactorily. 
In  many  instances  we  can  only  arrive  at  a  probable  conclusion  after 
carefully  studying  the  attendant  complications. 

The  distribution  of  the  pain  is  of  importance.  If  all  the  branches  of 
a  nerve  are  affected,  we  are  warranted  in  the  belief  that  the  lesion  is 
situated  either  in  the  trunk  of  the  nerve  or  at  its  central  origin.  If  only 
one  branch  of  the  nerve  is  involved,  and  this  condition  persists  during 
the  entire  course  of  the  disease,  the  lesion  is  probably  situated  in  the 
affected  branch,  since  it  is  not  probable  that  a  lesion  which  is  situated  in 
the  trunk  of  a  nerve,  will  merely  select  the  fibres  going  to  one  branch. 
But  the  restriction  of  the  symptoms  to  a  small  branch  does  not  posi- 
tively exclude  the  central  nature  of  the  affection,  since  the  fibres  of  the 
nerve  diverge  at  the  centres,  and  we  can  readily  understand  that  a 
central  lesion  may  involve  one  set  of  fibres  or  cells,  to  the  exclusion  of 
others. 

When  motor  and  trophic  disturbances  are  observed  within  the  dis- 
tribution of  the  nerve  which  is  the  seat  of  pain,  the  lesion  is  almost 
undoubtedly  situated  in  the  trunk  of  the  nerve.  This  is  not  true  in  all 
cases,  as  these  complications  may  be  reflex  in  their  character,  but  in  such 
an  event  they  will  not  often  be  strictly  confined  to  the  course  of  the 
painful  nerve. 

Neuralgias  which  form  complications  of  cerebral  or  spinal  diseases 
are  accompanied  by  the  symptoms  of  tlie  primary  affections.  Cerebral 
diseases  are  accompanied  by  disorders  of  the  special  senses,  or  of  the 
other  cranial  nerves,  paralysis  of  one  or  more  limbs  (usually  on  one  side 


NEUKALGIA.  Ill 

of  the  body),  epileptiform  convulsions,  disturbances  of  the  intellect,  etc. 
Spinal  cord  diseases  are  attended  by  oculo-pupillary  disorders  (when  the 
lesion  is  in  the  upper  part  of  the  cord),  motor  paralysis  (frequently  of  a 
paraplegic  type),  atrophy  of  muscles,  increased  or  diminished  reflex 
excitability,  sensory  disturbances  (usually  anjcsthesia),  interference  with 
the  functions  of  the  bladder  and  rectum,  etc. 

Tlie  prognosis  of  neuralgia  depends  entirely  upon  that  of  its  under- 
lying cause.  If  due  to  an  organic  lesion,  the  prognosis  will  depend  upon 
that  of  the  latter  affection,  whether  it  is  of  such  a  nature  as  to  permit 
removal  by  internal  medication  or  by  the  knife,  or  whether  it  is  of  a  cen- 
tral nature  and  not  amenable  to  treatment. 

When  due  to  a  constitutional  cause,  the  prognosis  again  depends 
upon  the  character  of  the  primary  disease.  Thus,  a  syphilitic  neuralgia 
presents  an  excellent  prognosis,  while  one  occurring  as  the  result  of  a 
tuberculous  cachexia  almost  always  continues  until  the  death  of  the 
patient. 

Neuralgias  of  old  age  present  a  gloomy  prognosis,  although  this  is 
not  so  absolutely  unfavorable  as  Trousseau  would  have  us  believe.  We 
may,  however,  regard  it  as  a  general  rule  that  a  neuralgia  which  develops 
after  the  age  of  sixty  will  continue  (usually  with  increasing  severity) 
until  the  death  of  the  sufferer. 

Those  cases  which  are  due  to  heredity  do  not  present  any  especially 
bad  prognosis  with  regard  to  the  individual  attacks,  but  they  manifest  a 
greater  liability  to  relapse  and  to  the  transformation  of  the  disease  into 
some  other  neurosis. 

The  large  class  of  neuralgias  which  is  caused  by  anasmia,  etc.,  usually 
furnishes  a  favorable  prognosis,  and  this  improves  so  much  the  more,  the 
earlier  the  patient  comes  under  treatment.  After  neuralgias  have  lasted 
for  a  long  time,  secondary  changes  are  apt  to  develop  in  the  nerves  and 
surrounding  tissues,  and  these  react  unfavorably  upon  the  course  of  the 
disease.  As  we  shall  see  at  a  later  period,  the  locality  of  the  pain  also 
possesses  considerable  influence  upon  its  prospects  as  regards  a  speedy 
or  tardy  recovery. 


CHAPTER  Y. 

TREATMENT. 

In  treating  neuralgias,  we  should,  above  all,  endeavor  to  determine 
the  cause  of  the  disease,  and,  if  possible,  attempt  its  removal.  Thus,  in 
malarial  neuralgias,  the  exhibition  of  large  doses  of  quinine  will  usually 
cause  the  disappearance  of  the  neuralgic  symptoms.  In  many  chronic 
cases,  however,  quinine  fails  us,  and  we  are  then  compelled  to  resort  to 
some  form  of  arsenic.  I  usually  prescribe  Fowler's  solution  in  five-drop 
doses  t.i.d.,  and  rapidly  increase  by  addition  of  a  drop  to  each  dose 
until  gastric  irritability  or  oedema  of  the  lower  lids  begins  to  develop. 
The  drug  is  then  discontinued  for  a  few  days,  until  the  gastric  irritation 
has  subsided,  after  which  it  is  administered  in  doses  slightly  smaller  than 
those  which  sufficed  to  produce  the  gastric  symptoms.  It  may  now  be 
continued  in  this  manner  for  a  long  time  without  giving  rise  to  any  dis- 
agreeable effects  (it  should  be  given  in  a  little  water  immediately  after 
each  meal,  before  the  patient  rises  from  the  table).  In  addition  to  the 
use  of  Fowler's  solution,  benefit  is  also  derived  in  these  chronic  cases 
from  cool  sponge-baths  of  the  entire  body,  followed  by  vigorous  shampoo- 
ing, and  from  the  administration  of  brandy  or  whiskey. 

In  syphilitic  neuralgias,  the  treatment  varies  according  to  the  charac- 
ter of  the  disease.  When  the  pain  is  produced  without  any  local  lesion 
in  the  affected  nerve,  the  greatest  benefit  is  derived  from  the  use  of  some 
form  of  mercury  ;  when  the  neuralgia  is  due  to  pressure  upon  the  nerves 
from  syphilitic  periostitis,  etc.,  or  to  syphilitic  changes  in  the  nerves 
themselves,  we  must  employ  iodide  of  potassium.  As  we  have  previously 
remarked  concerning  the  nervous  manifestations  of  tertiary  syphilis,  we 
should  only  stop  at  that  dose  of  the  iodide  which  cures  the  affection. 
We  may  begin  with  ten  to  fifteen  grains  t.i.d.,  and  increase  this  dose 
as  the  necessities  of  the  case  demand.  Relief  is  usually  experienced 
within  a  few  days.  Syphilitic  neuralgias  are  not  infrequently  the  fore- 
runners of  more  serious  affections  of  the  nervous  system,  and  the  admin- 
istration of  the  iodide  should  therefore  be  continued  for  one  or  two 
years  after  the  disappearance  of  the  symptoms. 

In  the  comparatively  rare  cases  of  true  rheumatic  neuralgias  excel- 
lent results  are  obtained  from  the  administration  of  salicylic  acid.  I 
generally  make  use  of  the  following  formula  : 

^ .     Acid  salicylic 3  ij- 

Sodas  bicarb 3  ij. 

Glycerinse, 

Aquae , aa  ?  ij. 

M. 

Of  this  mixture,  one  tablespoonful  is  to  be  taken  three  times  a  day, 
shortly  after  eating,  until  slight  evidences  of  intoxication  become  mani- 
fest. 


NEURALGIA.  113 

In  those  cases  in  ^;vhlch  heredity  or  an  acquired  neuropathic  disposi- 
tion plays  an  important  part,  the  tone  of  the  nervous  system  is  lowered, 
and  We  must  endeavor  to  improve  it  by  moans  of  rest  and  generous 
food.  • 

Whenever  jpossible,  prophylactic  measures  should  be  adopted,  and 
these  refer  especially  to  the  education  of  the  patients.  Childhood  and 
youth  are  rarely  subject  to  neuralgia,  and  a  great  deal  may  be  done  at 
this  time  to  elevate  the  tone  of  the  nervous  system,  and  tiius  prevent  the 
development  of  neuralgia  at  a  later  period.  The  children  should  not  be 
allowed  to  go  to  school  until  the  ages  of  seven  and  eight,  and  should  not 
be  subjected  to  the  "cramming"  method  of  education.  From  a  physi- 
cal point  of  view,  the  plan  adopted  should  be  that  known  as  the  "hard- 
ening" method.  The  patients  should  be  subjected  to  daily  cold  wash- 
ings or  baths,  regulated  and  moderate  gymnastics,  an  abundant  and 
varied  diet,  and,  especially,  sufficient  sleep.  Our  invariable  advice  in 
these  cases  is,  "  Let  the  patients  eat  as  much  as  their  stomachs  will 
digest,  and  sleep  as  long  as  they  can."  When  the  patients  arrive  at 
more  mature  years,  they  should  abstain  from  mental  overwork,  and  shun 
alcoholic  and  sexual  excesses.  The  care  of  the  eyes  is  also  an  important 
element,  and  their  condition  should  always  be  investigated  when  the 
patient  is  greatly  occupied  in  reading  or  writing,  fine  needlework,  or  any 
pursuit  in  which  the  eyes  are  subject  to  continuous  strain. 

These  measures  are  important,  not  alone  to  prevent  the  production  of 
neuralgia,  but  also  because  such  patients  are  apt,  under  adverse  circum- 
stances, to  develop  other  neuroses. 

A  large  number  of  cases  are  due  to  anremia,  and  we  must  then,  of 
course,  resort  to  ferruginous  tonics.  The  nature  of  the  iron  preparation 
is  not  very  important,  but  the  carbonate  of  iron  and,  at  the  present  time, 
dialyzed  iron,  are  most  in  vogue.'  In  addition,  we  must  eudeajt'or  to 
ascertain  and  remove  the  cause  of  the  anfemia. 

When  the  neuralgia  is  produced  by  local  causes,  or  when  it  is  of  a  peri- 
pheral nature,  special  treatment  is  required.  Thus,  when  the  affection  is 
due  to  the  presence  of  a  foreign  body,  the  pressure  of  a  tumor  or  cicatrix 
upon  the  nerve,  etc.,  surgical  interference  must  be  resorted  to  in  order  to 
remove  the  offending  substance. 

When  no  cause  can  be  determined,  or  when  it  is  of  an  organic  nature 
and  cannot  be  removed,  symptomatic  treatment  is  indicated.  Among 
such  measures,  the  use  of  morpliine  as  a  palliative  is  probably  resorted 
to  most  frequently.  In  some  cases  it  acts  not  alone  as  a  palliative,  but 
also  as  a  direct  curative  agent.  Not  very  infrequently,  a  severe  neuralgia 
will  be  permanently  relieved  by  the  administration  of  a  sufficiently  large 
dose  of  morphine.  It  vrould  seem,  in  such  cases,  as  if  the  entire  relief 
from  pain  procured  by  its  administration  breaks  the  "painful  habit"  of 
the  nerve,  and  thus  allows  it  to  recover  its  tone.  We  must  be  very  cau- 
tious, however,  about  beginning  the  use  of  morphine  in  neuralgia,  and 
should  not  resort  to  it  unless  compelled  by  the  severity  of  the  pain. 
Whenever  it  does  become  necessary,  the  morphine  should  be  administered 
hypodermically,  not  only  because  it  acts  more  quickly  when  given  in  this 
manner,  but  also  because  a  smaller  dose  is   required  to  produce  a  given 

'  We  should  bear  in  mind  that  iron  preparations  should  always  be  given  in  very 
small  doses,  not  alone  because  only  a  small  quantity  is  absorbed,  but  also  because  tha 
unabsorbed  portion  quickly  interferes  with  the  intestinal  functions. 
8 


114  FUNCTIONAL    NEKVOUS   DISEASES. 

effect.  The  only  objection  to  this  method  of  administration  is  that  the 
opium  habit  develops  more  readily  than  when  the  morphine  is  given  by 
the  mouth.  After  a  vphile,  of  course,  the  dose  must  be  increased;  and  in 
chronic,  incurable  cases,  almost  incredible  quantities  of  the  different  forms 
of  opium  are  taken.  It  is  immaterial  whether  the  injection  is  made  over 
the  course  of  the  painful  nerve,  or  at  a  distance  from  it.  No  definite 
statements  can  be  made  concerning  the  dose,  as  this  must  vary  with  the 
severity  of  the  pain  and  the  known  peculiarities  of  the  patient. 

Atropine  is  also  useful  as  a  palliative,  though  not  so  generally  ap- 
plicable as  morphine.  It  may  be  administered  either  hypodermically  or 
by  the  mouth,  and  I  have  noticed  as  a  curious  fact,  with  regard  to  this 
drug,  that  it  sometimes  acts  more  quickly  and  powerfully  when  given  by 
the  mouth  than  when  it  is  introduced  hypodermically.  The  initial  dose 
is  from  gr.  -gJg- — -^-^,  to  be  repeated  as  the  pain  returns,  until  evidences  of 
its  physiological  effects  (dilated  pupils,  dry  throat,  red  face  and  chest,  rapid 
pulse)  become  apparent,  after  which  the  remedy  is  to  be  discontinued 
until  these  symptoms  have  subsided.  Very  many  persons  are  peculiarly 
susceptible  to  atropine,  and  I  have  seen  the  above  mentioned  physiolo- 
gical effects,  with  the  addition  of  restlessness  and  a  tendency  to  delirium, 
following  the  administration  of  one  one-hundredth  of  a  grain.  These 
phenomena  sometimes  persist  for  two  or  three  days  (in  one  case  we  found 
them  last  a  week)  after  the  discontinuance  of  the  drug.  But  its  palli- 
ative effects  cannot  be  compared  with  those  of  morphine,  and  it  should 
only  be  used  when  the  patient  presents  an  idiosyncrasy  with  regard  to 
the  latter,  or  when  it  fails  to  produce  the  desired  effect. 

We  also  wish  to  refer  to  the  sedative  action  of  hypodermic  injections 
of  simple  water.  This  plan  is  not  much  employed,  but  we  have  found  it 
useful  in  quite  a  number  of  cases.  In  order  to  relieve  pain  by  this 
method,  we  merely  inject  a  hypodermic  syringeful  of  water  into  the  sub- 
cutaneous cellular  tissue.  When  this  method  was  first  proposed  (we  for- 
get the  name  of  its  inventor)  hot  Avater  was  used,  but  we  have  since 
found  that  similar  effects  are  produced,  whatever  the  temperature  of  the 
water  may  be.  Sometimes  the  injection  of  one  syringeful  of  water  will 
relieve  the  most  intense  pain  within  a  few  moments,  at  other  times  the 
sedative  action  develops  slowly,  and  several  minutes  elapse  before  its 
effects  are  produced.  In  the  majority  of  cases,  however^  it  produces 
little  or  no  effect,  and  we  are  unable  to  determine  beforehand  what  the  re- 
sult of  this  manipulation  will  be.  It  would  be  well  if  systematic  inves- 
tigations were  instituted,  in  order  to  determine  to  what  cases  this  method 
is  applicable.  Its  modus  operandi  in  relieving  pain  is  unknown,  but  that 
the  opinion  which  attributes  its  sedative  action  to  the  results  of  the  im- 
agination is  erroneous,  is  proven  by  the  following  personal  case,  which  is 
interesting  in  very  many  other  particulars  : 

Case  II. — Mrs.  A.  B.,  fet.  54  years,  married;  no  hereditary  tendency 
known,  but  her  children  present  a  marked  neuropathic  disposition  (epi- 
lepsy, hysteria,  nervosisme).  Two  years  ago  (1873),  Mrs.  B.  injured  her 
left  breast  as  she  was  leaving  a  street  car,  and  soon  afterward  a  small, 
hard,  painless  lump  appeared  at  the  site  of  injury;  subsequent  develop- 
ments proved  this  to  be  a  scirrhous  growth. 

I  was  first  called  to  see  the  patient  toward  the  end  of  April,  1ST5, 
and  found  lier  suffering  from  a  violent  attack  of  neuralgia,  the  pain 
migrating  iiito  various  parts  of  the  trunk  and  upper  extremities;  the 
attack  had  developed  quite   suddenly.     After  a  few  days  the  zieuralgic 


NEURALGIA.  115 

affection  became  strictly  periodical  in  its  appearance,  being  attended  with 
severe  chills  and  regularly  intermittent  variations  in  temperature  of  the 
quotidian  type.  At  the  end  of  a  week  the  attack  succumbed  to  forty-five 
grain  doses  of  quinine  i^er  diem.  The  patient  remained  well  for  only 
three  weeks,  when  the  neuralgia  recurred,  the  pains  becoming  gradually 
more  and  more  atrocious  in  character.  This  attack  lasted  until  the  mid- 
dle of  August.  None  of  the  many  drugs  emplo^^ed  produced  the  slight- 
est beneficial  effect  except  atropia,  which,  when  given  to  the  extent  of 
producing  marked  dilatation  of  the  pupils,  dryness  of  the  pharynx,  rapid 
pulse,  and  slight  tendency  to  delirium,  produced  considerable  relief. 
After  using  it  for  a  few  weeks,  however,  it  became  entirely  iuefficient. 
A  peculiar  fact  noticeable  in  the  employment  of  the  atropine  was  that, 
when  administered  by  subcutaneous  injection,  it  produced  less  effect  than 
when  tlie  same  amount  was  given  by  the  mouth.  The  only  relief  that 
could  eventually  be  obtained  was  from  the  hypodermic  administration  of 
Magendie's  solution  of  morphine,  the  dose  of  which  was  finally  pushed  to 
250  drops ^je?'  diem  (often  as  many  as  400)  in  order  to  render  the  patient 
tolerably  comfortable.  In  conjunction  with  morphine,  I  employed  subcu- 
taneous injections  of  water.  And  here  it  may  be  well  to  mention  a  very 
curious  fact  with  regard  to  the  comparative  effect  on  this  patient  of  hypo- 
dermic injections  of  morphine  and  water.  The  former  always  produced 
a  more  profound  and  permanent  effect  in  relieving  pain  than  the  latter; 
but  while,  in  the  beginning  of  the  malady,  the  relief  experienced  from  the 
morphine  was  almost  instantaneous,  and  that  produced  by  the  water  only 
became  palpable  after  the  lapse  of  four  or  five  minutes,  toward  the  latter 
stages  of  the  disease  this  relation  was  reversed,  the  relief  experienced 
from  the  water  being  instantaneous,  while  that  from  the  morphine  was 
felt  only  after  the  lapse  of  several  minutes. 

The  neuralgic  pains  were  chiefly  confined  to  the  nerves  of  the  upper 
or  lower  extremities,  but  certain  of  the  intercostal  nerves  were  sometimes 
implicated;  at  no  period  during  the  entire  course  of  the  disease  did  any 
tenderness  on  pressure  exist  over  any  part  of  tlie  spinal  column.  The 
neuralgia  continued,  with  short  intermissions  and  continually  increasing 
severity,  and  was  only  terniinated  by  death  (January  31,  1877),  the  im- 
mediate cause  of  which  was  acute  pleurisy  of  the  left  side,  complicated 
with  oedema  of  the  lungs. 

Autopsy. — The  results  of  the  autopsy,  which  want  of  time  prevented 
me  from  making  as  carefully  as  was  desirable,  were  substantially  as  fol- 
lows: 

JBrain. — Dura  mater  :  slight  pachymeningitis  over  the  convexity  of 
both  cerebral  hemispheres;  a  few  small  cancerous  nodules  were  scattered 
over  the  inner  surface  of  dura  mater;  calvarium  normal. 

Spi7icd cord. — Only  the  dorsal  portion  of  the  cord  could  be  examined; 
the  cord  itself  was  entirely  free  from  disease;  dura  mater:  slight  pachy- 
meningitis, apparently  of  about  the  same  date  as  the  cerebral;  this  mem- 
brane was  very  firmly  adherent  to  the  vertebrcC,  and  minute  carcinoma- 
tous deposits  projected  from  its  inner  surface. 

J^ertebrce. — The  bodies  and  laminae  of  the  dorsal  vertebrae  (which  were 
the  only  ones  examined)  were  infiltrated  with  the  cancerous  neoplasm  to 
such  an  extent  that  they  could  be  cut  with  the  knife;  there  was  no  mal- 
formation of  the  vertebrEe.  The  long  bones  of  the  body  could  not  be  ex- 
amined. 

3Iamma. — The  tumor  of  the  left  breast  was  nearly  as  large  as  a  hen's 
^gg}  and  presented  the  ordinary  appearances  of  scirrhous  cancer. 


116  FUNCTIONAL    NERVOUS    DISEASES. 

Ijungs. — Right  lung  slightly  cedematous;  pleura  normal;  under  the 
right  pleura,  and  growing  from  the  ribs,  were  a  few  small  cancerous  nod- 
ules. Left  lung  slightly  a?dematous;  left  pleura  coated  with  fibrinous 
exudation;  small  amount  of  fluid  in  pleural  cavity. 

Liver. — Surface  perfectly  smooth;  size  of  the  organ  perhaps  a  trifle 
greater  than  normal;  liver-tissue  largely  infiltrated  with  carcinoma,  the 
deposits  varying  in  size  from  that  of  a  pea  to  a  walnut.  The  consistence 
of  the  new  growth  was  a  little  firmer  than  that  of  the  normal  liver-tissue; 
the  carcinomatous  portions  occupied  at  least  one-half  of  the  entire  bulk 
of  the  liver. 

Ovaries. — Right  ovary  was  transformed  into  a  scirrhous  mass  of  ap- 
parently homogeneous  structure,  which  had  attained  almost  the  size  of  a 
goose-egg. 

The  other  organs  were  normal. 

Histological  appearances. — The  new  growths  in  all  the  organs  pre- 
sented the  appearances  of  carcinoma  simplex  of  a  rather  small-celled  va- 
riety; in  some  places  the  amount  of  stroma  present  was  very  much 
diminished,  constituting  the  softer  variety  of  cancer;  in  other  places  tlie 
relative  proportion  of  stroma  to  cells  became  reversed,  and  the  growth 
presented  the  appearances  of  scirrhus. 

We  will  next  consider  the  class  of  remedies  known  as  counter-irritants, 
which  include  the  ordinary  fly-blister,  cantharidal  collodion,  bisulphide  of 
carbon,  electricity,  and  the  actual  cautery.  I  formerly  made  much  more 
extensive  use  of  counter-irritants  in  the  treatment  of  neuralgia  than  I  do 
at  the  present  time,  and  how  restrict  their  employment  almost  exclusively 
to  those  cases  in  which  there  is  marked  tenderness  over  the  spinous  pro- 
cess corresponding  to  the  affected  nerve  (^vo^\^%&^^x'?,  point  apophysaire). 
In  such  cases  counter-irritants  usually  act  admirably;  in  occipital  neural- 
gia we  have  found  that  the  application  of  one  or  two  blisters  is  generally 
sufficient  to  relieve  the  pain  entirely.  The  use  of  the  ordinary  fly-blister 
and  of  cantharidal  collodion  is  so  common,  that  it  is  unnecessary  to  dwell 
upon  their  mode  of  application. 

The  bisulphide  of  carbon  is  employed  by  pouring  a  few  drops  upon 
some  cotton  and  then  applying  this  to  the  skin,  the  cotton  being  pressed 
firmly  against  the  integument  in  order  to  prevent  evaporation.  Within 
one  or  two  minutes  severe  pain  begins  to  be  felt,  and  the  skin  is  then 
found  intensely  reddened.  The  cotton  should  not  be  applied  more  than 
two  minutes,  as  the  pain  continues  to  increase  for  a  little  while  after  its 
removal,  and  would  soon  become  unendurable.  Although  the  bisulphide 
produces  counter-irritation  very  rapidly,  and  is  quite  ready  of  application, 
it  possesses  the  inconveniences  of  being  very  painful,  and  also  of  being 
excessively  foetid. 

Electricity  may  also  be  employed  as  a  counter-irritant.  For  this  pur- 
pose we  use  the  strongest  secondary  faradic  current  which  the  patient 
can  bear,  the  electrode  consisting  of  a  wire  brush.  This  is  applied  over 
the  part  to  be  irritated,  the  brush  being  either  pressed  firmly  against  the 
skin  or  gently  stroked  to  and  fro  across  the  surface.  The  counter-irrita- 
tion is  developed  within  a  few  moments,  and  disappears  very  soon  after 
the  electrode  is  removed;  while  the  brush  is  in  contact  with  the  skin, 
however,  the  pain  is  very  intense,  and  considerable  fortitude  is  necessary 
in  order  to  tolerate  it  for  even  a  few  seconds. 

The  actual  cautery  with  the  hot  iron  is  generally  included  under  the  head 
of  counter-irritants,  but  we  think  that  it  is  erroneously  classed  among 


NEURALGIA.  117 

tliese  asrents.  Paquelin's  cautery  may  be  employed,  or  an  ordinary  blast- 
lamp,  using-  either  a  glass  or  an  iron  rod.  When  neither  of  these  instru- 
ments can  be  obtained,  a  poker  heated  in  a  good  coal  fire  will  suffice  for 
ail  practical  purposes.  Most  authorities  state  that  the  iron  should  be 
wiiite-hot,  but  this  is  not  necessary,  and  I  have  always  found  that  a 
cherrv-red  heat  will  answer  very  well.  There  is  a  widespread  feeling 
ainony-  the  laitv  (which  has  been  fostered  by  blood-curdling  newspaper 
articles),  that  the  application  of  the  actual  cautery  is  an  heroic  measure, 
entailing  excruciating  agony.  But,  on  the  contrary,  its  application  is 
almost  entirely  painless  when  properly  performed.  The  iron  should  be 
applied  verv  gentlv  and  rapidly  to  the  skin,  so  as  to  leave  no  scar  orsup- 
puratinof  sore,  and  the  entire  operation  only  lasts  a  fraction  of  a  second. 
In  fact,  the  pain  is  sometimes  so  insignificant,  that  I  have  used  the  iron 
without  the  knowledge  of  the  patient,  and  whenever  I  could  rely  upon 
the  statements  of  my  patients  in  this  regard,  they  have  always  informed 
me  that  the  pain  of  the  application  was  not  worth  mentioning.  It  may 
either  be  emploved  on  the  spine  or  along  the  course  of  the  affected 
nerves.  It  is  a  singular  fact  that  the  pain  may  sometimes  be  relieved  by 
the  application  of  the  cautery  to  a  distant  part  of  the  body.  Thus,  there 
are  quite  a  number  of  authentic  cases  on  record  in  which  the  application 
of  the  cautery  to  the  lobe  of  the  ear  has  relieved  an  attack  of  sciatica 
(this  plan  was  borrowed  from  veterinary  practice).  The  manner  in  which 
the  actual  cautery  produces  its  beneficial  effects  is  unknown,  but  there  is 
no  doubt  that  it  sometimes  relieves  neuralgia  as  if  by  magic.  Even  pains 
which  are  due  to  an  incurable  organic  affection,  like  locomotor  ataxia,  may 
be  relieved  by  its  agency.  It  presents  this  advantage  over  the  ordinary 
methods  of  counter-irritation,  that  it  produces  no  subsequent  pain  or  an- 
noyance, even  if  it  proves  unsuccessful  as  a  palliative. 

Electricity  has  also  been  extensively  used  as  a  palliative  measure,  and 
both  currents  have  been  employed.  The  faradic  current  is  employed  in 
two  wavs,  viz.:  with  the  wire  brush,  and  with  the  aid  of  sponge  electrodes 
placed  along  the  course  of  the  nerves.  The  former  method  is  really  a 
form  of  counter-irritation,  and  we  have  previously  discussed  it  under  that 
heading.  The  second  method,  viz. :  that  in  which  sponge  electrodes  are 
placed  along  the  course  of  the  affected  nerve,  is  not  very  much  employed 
at  present.  My  own  experience  with  it  has  been  so  unsatisfactory,  that 
I  have  entirely  discarded  it  for  several  years  past. 

The  use  of  galvanism,  however,  in  the  treatment  of  neuralgia  is 
attended  with  much  greater  benefit  than  that  derived  from  the  faradic 
current.  It  is  a  much  more  valuable  measure  in  peripheral  neuralgias, 
and  those  in  which  there  is  no  gross  anatomical  lesion,  than  in  central 
ones,  due  to  an  organic  lesion.  The  majority  of  authors  advocate  the 
use  of  the  descending  current.  When  I  first  began  the  systematic  use  of 
galvanism  in  the  treatment  of  neuralgias,  I  also  complied  strictly  with 
this  rule  until  I  discovered  accidentally,  while  galvanizing  the  sciatic 
nerve  of  a  patient  suffering  from  sciatica,  that  equal  relief  was  experi- 
enced when  the  current  was  passing  in  the  opposite  direction.  I  have 
had  such  frequent  opportunity  of  verifying  this  experience,  that  I  have 
become  convinced  that  the  direction  of  the  current  is  entirely  immaterial. 

The  usual  method  of  applying  the  galvanic  current  is  to  place  one 
electrode  over  the  tender  point  which  is  present  along  the  spinal  column, 
or,  when  this  is  absent,  along  the  course  of  the  nerve,  and  the  other  elec- 
trode farther  down  in  the  course  of  the  nerve  near  its  peripheral  distri- 
bution.    The  strength  of  the  current  employed  should  vary  according  to 


118  FUNCTIONAL   NERVOUS    DISEASES. 

the  susceptibility  of  the  patient.  Beg-inning  with  a  mild  current,  its  in- 
tensity is  gradually  increased,  until  a  disagreeable  burning  sensation  is 
produced,  and  the  current  is  then  allowed  to  flow  uninterruptedly  for  a 
period  varying  from  five  to  ten  minutes.  This'  shoud  l)e  repeated  daily 
or  every  other  day.  We  are  usually  able  to  determine  after  the  first  sit- 
ting whether  the  current  will  have  a  beneficial  effect  or  not.  In  favorable 
cases  a  distinct  amelioration  of  the  pain  is  produced  lasting  from  half  an 
hour  to  one  or  even  two  days,  and  when  this  palliative  effect  is  naarked, 
the  patient  is  usually  cured  in  from  one  to  three  weeks.  As  a  rule,  to 
which  there  are  occasional  exceptions,  the  cases  will  not  be  relieved  if  the 
cure  is  not  complete  within  three  or  four  weeks  after  beginning  galvanic 
treatment.  We  will  find,  in  the  course  of  our  remarks  on  the  special 
forms  of  neuralgia,  that  some  varieties  are  more  susceptible  to  the  influ- 
ence of  galvanism  than  others. 

We  will  next  consider  the  action  of  those  remedies  which  appear  to 
have  a  special  effect  on  neuralgic  affections. 

The  number  of  these  so-called  specifics  is  legion,  but  there  are  not 
many  which  possess  any  great  value.  We  will  only  refer  to  those  from 
which  we  have  derived  benefit  in  practice.  These  include  strychnia,  ar- 
senic, phosphorus,  gelsemium,  aconitia,  bromide  of  potassium,  oil  of  tur- 
pentine, nitrite  of  amyl. 

We  have  only  obtained  good  results  from  strychnia  in  trigeminal  and  sci- 
atic neuralgias,  and  in  the  last  couple  of  years  have  limited  its  use  almost 
entirely  to  the  treatment  of  the  latter  affection.  While  we  do  not  claim  for 
it  a  specific  action  in  this  disease,  we  are  nevertheless  convinced  that  it 
relieves  more  cases  than  any  other  single  remedy.  We  should  begin  its 
use  in  doses  of  one-forty-eighth  of  a  grain  given  three  times  a  day,  and 
can  then  increase  the  quantity  administered  by  one  teaspoonful  daily  un- 
til the  phosiological  effects  are  produced  (stiffness  in  the  lower  limbs, 
and  sometimes  slight  spasms,  increased  reflex  excitability,  pain  in  the 
throat,  nervousness).  In  bad  cases,  the  patient  should  be  kept  slightly  un- 
der the  influence  of  the  drug  for  two  or  three  weeks,  and  if  recovery  does 
not  occur  in  that  period,  it  will  be  useless  to  continue  its  administration. 

The  patient  should,  however,  be  carefully  watched  during  the  entire 
period  of  its  exhibition,  and  the  drug  discontinued  as  soon  as  marked 
effects  become  evident.  Some  patients  are  extremely  susceptible  to  its 
influence,  and  I  have  seen  a  vigorous  adult  suffer  severely  from  the  ad- 
ministration of  three  doses  of  one-forty-eighth  of  a  grain  which  were  taken 
in  the  course  of  twenty-four  hours. 

Arsenic  frequently  does  good  service.  It  is  preferably  administered 
in  the  form  of  Fowler's  solution  (beginning  with  five  drops  three  times  a 
day  and  gradually  increasing  up  to  ten  or  twelve  drops  at  a  dose). 

This  drug  is  one  of  the  best  nerve-tonics  with  which  we  are  acquainted, 
and  may  be  administered  with  benefit  for  a  very  long  time.  It  is  useful, 
at  times,  in  all  forms  of  neuralgia,  but  is  especially  serviceable  in  those 
varieties  which  are  apparently  combined  with  degeneration  of  blood- 
vessels occurring  in  old  age  or  in  hard  drinkers. 

Phosphorus,  from  its  presence  in  the  tissues  of  the  brain,  was  regarded, 
in  former  times,  as  a  sine  qua  non  in  the  treatment  of  functional  nervous 
diseases.  It  was,  however,  gradually  losing  its  prestige  in  the  treatment 
of  neuralgia,  when  it  was  again  brought  strongly  to  the  notice  of  the  pro- 
fession by  Thompson.  My  own  experience  has  not  been  very  satisfactory 
with  this  agent,  and  I  now  limit  its  use  to  those  cases  which  are  accom- 
panied  by   evidences  of  nervous  depression,  especially  when  caused  by 


NEURALGIA.  119 

mental  overwork.  Squibb's  solution  of  phosphorus  in  cod-liver  oil  fur- 
nishes a  very  nice  method  of  administration,  but  I  have  usually  employed 
it  in  combination  with  strychnia  and  quinine,  adoptin<j  the  formula  known 
as  the  Hammond  mixture. 

1^ .    Strychnije  sulph gr.  i. 

Ferri  pyrophosphatis, 

Quinife  sulph iia     3  i. 

Acid  phosphor,  dil., 

Syr,  zingiberis aa    3  ij. 

M.    Sig.  —  3  i-  t.i.d. 

Gelsemium  sempervirens  had  been  long  employed  in  this  country  in 
the  treatment  of  neuralg'ia,  but  it  did  not  meet  with  general  favor  until 
the  seal  of  European  approbation  had  been  placed  upon  it.  This  druo- 
has  been  chiefly  used  in  trigeminal  neuralgia,  especially  in  the  dental 
forms,  and  my  own  experience  conforms  with  that  of  most  observers  who 
have  used  the  remedy,  viz. :  that  it  relieves  some  cases  with  great  rapiditv, 
while  others  of  an  apparently  similar  nature  are  not  benefited  in  the 
least.  The  fluid  extract  is  the  most  reliable  preparation,  and  may  be 
given  in  doses  of  gtt.  v.  to  x.,  t.i.d.  The  patient  should  be  carefully 
watched  while  the  drug  is  being  administered,  as  it  has  a  very  powerful 
paralyzing  action  upon  the  heart,  and  may  very  rapidly  produce  great 
muscular  prostration. 

Aconitia  had  been  recommended  in  neuralgia  by  Benj.  Brodie  and  bv 
Romberg,  but  afterward  fell  into  disuse  until  extolled  in  the  highest  terms 
by  Gubler  several  years  ago.  In  this  country.  Dr.  Seguin  was  prominent 
in  bringing  it  into  public  notice,  and  for  a  year  or  more,  I  have  used  it 
extensively.  I  must  confess,  however,  that  my  expectations  with  res"ard 
to  the  effects  of  this  drug  have  not  been  entirely  realized.  While  it  pro- 
duced decided  relief  in  the  larger  number  of  cases  in  which  it  was  used, 
it  produced  a  complete  cure  in  only  a  few.  When  the  preparation  is 
good  (Duquesnel's  aconitia'  is  the  only  reliable  article),  it  is  an  extremely 
powerful  poison  (only  equalled  in  virulence,  perhaps,  by  nicotine)  and 
should  be  given  in  exceedingly  small  doses. 

The  dose  is  from  yfo — jij  °^  ^  grain,  given  three  times  a  day,  and 
this  may  be  increased  by  one  dose  daily  until  the  physiological  effects 
(dryness  of  the  throat,  slowness  of  the  pulse,  and  tingling  of  the  tongue, 
roof  of  the  mouth,  and  tips  of  the  fingers)  are  produced.  If  immedi- 
ate relief  is  not  obtained,  it  should  be  continued  for  several  weeks  before 
being  discarded.  Although  this  remedy  does  not  fulfil  the  enthusiastic 
encomiums  of  Prof.  Gubler,  it  will,  I  think,  be  found  to  be  one  of  the  most 
generally  useful  of  all  anti-neuralgics,  and  in  some  even  desperate  cases 
the  pain  is  found  to  disappear  as  soon  as  the  patient  is  fully  under  its  in- 
fluence. I  also  wish  to  emphasize  the  fact  that,  whenever  necessary  in 
the  treatment  of  neuralgias,  the  remedies  employed  should  be  pushed 
to  the  production  of  their  full  physiological  effects,  before  they  are  re- 
nounced as  useless.  The  physician,  although  avoiding  recklessness, 
should  be  bold  in  the  use  of   his  medicinal  armamentarium. 

'  Sir.  Rice,  chemist  to  Bellevtie  Hospital,  informs  me  by  verbal  communication, 
that  Duqiicsnel's  aconitia  is  composed  of  aconitia  proper  and  of  pseudo-aconitia.  the  ef- 
fects of  the  latter  being  directly  antagonisric  to  those  of  the  former.  An  English  pre- 
paration of  aconitia,  which,  according  to  Mr.  Rice,  is  chemically  pure,  will  soon  appear 
in  the  market. 


120  rUNCTIOJSTAL   NERVOUS   DISEASES. 

Bromide  of  potassium  was,  at  one  time,  regarded  as  a  panacea  for  a 
considerable  number  of  nervous  disorders,  and  neuralgia  was  also  included 
in  this  category.  But  it  has  no  direct  palliative  effect  whatever  in  the 
latter  disease.  It  is  useful  in  those  cases  which  are  complicated  with  hys- 
teria, or  with  an  irritable  condition  of  the  nervous  system  arising  from 
any  source,  but  in  such  instances  it  merely  soothes  the  nervous  system, 
and  does  not  relieve  neuralgic  pain.  It  must,  therefore,  alwaj's  be  com- 
bined with  some  other  remedy,  and  large  doses  are  usually  required.  It 
is  given  to  advantage  with  hydrate  of  chloral  in  those  cases  in  which  the 
patients  suffer  from  insomnia,  when  this  condition  is  due  to  causes  other 
than  pain. 

Oil  of  turpentine,  though  very  little  employed  at  the  present  time, 
sometimes  proves  very  useful  in  chronic  cases  of  sciatica.  It  should  be 
given  in  doses  of  half  an  ounce  to  an  ounce,  immediately  after  meals. 

Nitrite  of  amyl  has  been  recommended  of  late  in  the  affection  under 
discussion,  and  quite  a  number  of  cases  have  been  reported,  in  which  it 
has  produced  happy  results.  My  own  experience  with  it  in  this  disease 
has  been  small,  and  while  my  results  have  not  been  very  striking,  they  are, 
however,  sufficiently  satisfactory  to  stimulate  to  further  trial.  The  nitrite 
of  amyl  should  be  administered  by  inhalations,  beginning  with  three-drop 
doses  three  times  a  day,  and  gradually  increasing,  as  the  necessities  of  the 
case  demand. 

Finally,  we  must  devote  a  little  attention  to  the  surgical  treatment  of 
neuralgia,  although  this  should  be  included,  strictly  speaking,  in  the 
province  of  the  practical  surgeon.  These  measures  include  neurotomy 
(nerve  section),  neurectomy  (excision  of  a  piece  of  a  nerve),  nerve 
stretching,  and  ligature  of  arteries. 

Although  it  has  been  very  conclusively  shown  that  cut  nerves  do  not 
unite  by  first  intention,  nevertheless  the  union  occurs  very  rapidly,  and 
there  is  some  reason  to  believe  that  the  regeneration  of  a  piece  two  inches 
in  length  will  not  occupy  a  longer  time  than  that  of  a  portion  only  a  frac- 
tion of  an  inch.  For  this  reason,  therefore,  simple  neurotomies  should 
not  be  resorted  to  whenever  neurectomy  can  be  performed,  and,  in  addi- 
tion, as  large  a  piece  of  the  nerve  as  possible  should  be  removed.  In  the 
operation  of  stretching  the  nerve  an  incision  is  made  along  the  length  of 
the  nerve,  and  the  latter  is  laid  bare  and  detached  from  surrounding  tis- 
sues; the  finger  is  then  introduced  beneath  the  nerve,  and  vigorous  trac- 
tion made.  When  this  operation  is  performed  upon  small  nerves,  the 
traction  must  be  exercised  with  great  caution  in  order  to  obviate  their 
rupture.  This  accident  happened  to  Czerny  while  stretching  one  of  the 
branches  of  the  trigeminus,  and  he  was  compelled,  in  consequence,  to  ex- 
sect  a  portion  of  the  torn  nerve.  The  inodus  operandi  of  the  relief 
obtained  by  the  operation  is  entirely  unknown. 

Ligature  of  the  carotid  has  been  employed  several  times  in  hopeless 
cases  of  tic  douloureux,  but  this  operation  should  only  be  resorted  to  as  a 
dernier  ressort. 

Surgical  interference  is  especially  indicated  when  the  disease  is  of  a 
peripheral  nature.  This  does  not,  however,  constitute  an  absolute  rule, 
as  neurectomy  has  been  known  to  produce  a  cure  when  the  neuralgia  was 
the  result  of  a  central  affection.  Such  an  effect  is  regarded  as  the  result 
of  an  "  alterative  "  action  upon  the  nutrition  of  the  central  nervous  sys- 
tem— another  method  of  expressing  our  ignorance.  Neurectomy  is  very 
rarely  dangerous,  but  it  should,  nevertheless,  be  only  used  as  a  last  resort. 
The   prognosis  of  the  operation,  as  regai'ds  complete  and  permanent  re- 


NEURALGIA.  121 

covery,  is  not  ver}''  good.  A  relapse  may  occur  long  after  the  operation, 
and  Gussenbauer  reports  one  case  in  which  the  disease  returned  five  years 
after  exsection. 

Five  years  ago  Arloing  and  Tripier  demonstrated  that  recurrent 
nerves  pass  from  the  peripheral  ramifications  of  one  nerve  to  those  of  ad- 
jacent ones,  and  therefore  pain  which  is  located  in  the  distribution  of  one 
nerve  may  be  attributed  to  an  affection  of  another,  and  perhaps  entirely 
healthy  one.  These  facts  are  of  great  importance,  not  alone  from  a  phy- 
siological, but  also  from  a  practical  standpoint.  They  teach  us  that  great 
caution  must  be  exercised  in  the  determination  of  the  nerve  to  be  oper- 
ated upon,  as  it  has  been  found,  on  more  than  one  occasion,  that  a  por- 
tion of  the  wrong  nerve  has  been  exsected,  and  a  second  operation  there- 
fore rendered  necessary.  We  will  discuss  this  subject  more  in  detail  in 
our  remarks  on  the  special  forms  of  neuralgia. 


CHAPTER  VI. 

TRIGEMINAL   NEUEALaiA,' 
(Prosopalgia.) 
Clinical  Histoky. 

Teigeminal  neuralgia  is  unilateral  in  almost  all  cases,  and  does  not  often 
affect  all  the  branches  of  the  nerve.  Whenever  this  is  the  case,  the  pain 
often  radiates  into  the  occipital  nerve  or  cervico-brachial  plexus.  The 
supraorbital  branch  is  by  far  the  most  frequently  involved;  and,  when 
this  occurs  in  a  malarial  patient,  the  affection  is  popularly  known  as 
brow-ague.  Any  nerve  twig  may,  however,  be  separateh^  implicated  to 
the  exclusion  of  all  the  others,  and  there  are  even  a  few  cases  on  record 
in  which  the  branch  going  to  the  tongue  was  alone  affected. 

The  paroxysm  of  pain  may  develop  with  extreme  rapidity,  but  there 
are  usually  some  prodomata  for  a  few  hours  before  the  onset.  These 
consist  of  a  feeling  of  "drawing "in  the  distribution  of  the  nerve,  of 
numbness,  slight  wandering  pains,  or  a  sensation  of  coldness.  Then 
slight  "  stitches  "  begin  to  run  along  the  nerve ;  they  soon  increase  in  sever- 
ity, and  appear  to  dart  with  fearful  rapidity  (sometimes  running  toward 
the  centre  as  well  as  toward  the  periphery).  A  lull  then  occurs,  during 
which  merely  a  numb  pain  is  appreciable;  but  this  calm  is  only  tempo- 
rar}',  and  is  interrupted  in  a  moment  or  two  by  another  attack  of  pain. 
The  entire  paroxysm  lasts  for  a  period  varying  from  a  few  minutes  to 
Sfcveral  hours.  Trousseau  has  described  one  variety  uuder  the  title 
epileptiform  neuralgia,  which  he  thinks  is  analogous  to,  and,  in  some  in- 
stances, is  an  expression  of  true  epilepsy.  This  form  develops  at  an 
ad\anced  age,  the  pain  is  extremely  intense  and  always  darting  in  char- 
acter, and  is  accompanied  by  convulsive  movements  of  the  side  of  the 
face  involved  (tic  douloureux).  The  patients  endeavor  to  mitigate  the 
pain  to  a  certain  extent  by  firmly  compressing  the  cheek  with  the  hand, 
and  this  may  be  done  so  forcibly  and  continuously  that  the  skin  is  par- 

'  The  trigeminus  is  divided  into  three  branches,  viz.,  the  ophthalmic,  superior 
maxillarj',  and  inferior  maxillary.  The  ojiJitJialmic  branch  supplies  the  lachrymal 
gland,  the  conjunctiva  and  integument  of  the  upper  lid,  the  skin  of  the  frontal  region 
as  far  as  the  vertex,  the  mucous  membrane  of  the  frontal  sinus,  the  ciliary  muscle  and 
iris,  the  integument  of  the  nose,  inner  surface  of  the  lower  lid,  the  lachrymal  sac, 
and  caruncula.  The  snpeiiw  mnxilUiry  branch  supplies  the  integument  of  the  temple 
and  side  of  the  forehead,  the  upper  teeth,  antrum,  lower  eyelid,  side  of  the  nose,  the 
integument  and  mucous  membrane  of  the  u;.per  lip.  The  inferior  maxillary  branch 
supplies  the  integument  of  the  temporal  region,  the  auditory  meatus  and  integument 
of  the  ear.  the  temporo -maxillary  articulation,  the  parotid  gland,  the  mucous  mem- 
brane of  the  tongue,  mouth,  and  gums,  the  lower  teeth,  integument  of  the  chin  and 
lower  part  of  the  face,  and  the  lower  lip. 


NEURALGIA.  123 

tially  rubbed  off  and  the  face  denuded  of  the  beard;  they  are  unable 
to  take  solid  food  for  fear  of  producin<^  a  paroxysm,  and  for  the  same 
reason  articulation  is  interfered  with,  since  even  the  movements  of 
the  cheek  may  give  rise  to  the  pain.  When  the  paroxysm  reaches  its 
height,  the  patients  may  become  delirious  for  a  few  moments  on  account 
of  the  atrocious  character  of  the  pains.  We  cannot  agree  with  Trous- 
seau's view  of  the  close  relationship  of  this  form  of  the  disease  with  epi- 
lepsy. To  our  mind  it  is  merely  a  severe  form  of  neuralgia,  occurring  at 
that  period  of  life  when  arterial  degeneration  is  going  on,  and  the  nutri- 
tion of  the  nerves  suffers  severely  in  consequence.  Nor  do  we  agree  with 
Trousseau  in  giving  such  an  extremely  unfavorable  prognosis  in  this  va- 
riety. These  cases  are,  at  times,  combined  with  melancholia,  and  this  is 
not  surprising  if  we  reflect  upon  the  intensity  of  the  sufferings  of  the  pa- 
tients and  upon  the  unfavorable  prospects  as  regards  recovery  which  is 
usually  offered  to  them  by  physicians. 

Puncta  dolorosa  are  very  commonly  observed,  and  are  readily  recogniz- 
able. The  following  ones  are  observed  in  neuralgia  of  the  ophthalmic 
branch:  a  supra-orbital  point,  at  the  supra-orbital  notch  or  foramen,  a 
parietal  point,  at  the  summit  of  the  parietal  protuberance,  a  nasal  point, 
at  the  upper  part  of  the  lateral  aspect  of  the  nose;  in  neuralgia  of  the 
superior  maxillary  branch,  we  find  an  infra-orhital  point,  at  the  infra-orbi- 
tal foramen,  a  nasal  point,  at  the  lower  part  of  the  lateral  aspect  of  the 
nose,  a  malar  point,  over  the  middle  of  the  malar  bone,  a  superior  gen- 
<7^yrt/ point,  in  the  upper  gums;  in  neuralgia  of  the  inferior  maxillary 
nerve,  a  temporal  point,  immediately  in  front  of  the  lobe  of  the  ear,  a 
mental  point,  at  the  mental  foramen,  and  an  inferior  gengival  point,  in 
the  lower  gums.  Other  puncta  dolorosa  have  been  mentioned  by  various 
writers,  but  these  are  the  only  ones  which  we  have  been  able  to  detect. 
We  must  also  refer  to  the  fact  that  Trousseau's  point  apophysaire  is  fre- 
quently observed  over  the  first  or  second  cervical  vertebrae,  though  it  is 
not  by  any  means  so  constant  as  the  distinguished  French  observer  be- 
lieved. Pressure  upon  the  tender  spinous  process  sometimes  sends  a 
thrill  of  pain  through  the  supraorbital  nerve. 

When  the  ophthalmic  branch  is  the  seat  of  the  disease,  numerous 
concomitant  symptoms  may  be  manifested.  The  most  frequent  are  in- 
tense redness  of  the  conjunctiva  and  profuse  secretion  of  tears;  there  is 
not  infrequently  an  erysipelatoid  condition  of  the  integument  of  the 
forehead.  The  hair  of  the  eyebrow  and  of  the  scalp,  in  the  distribution 
of  the  affected  nerve  may  turn  gray  or  become  brittle  or  coarse.  Her- 
pes as  a  complication  of  trifacial  neuralgia  is  almost  exclusively  limited 
to  the  distribution  of  the  ophthalmic  nerve  (herpes  ophthalmicus).  It  is 
usually  confined  to  the  upper  lid  or  forehead,  but  it  sometimes  involves 
the  cornea,  leading  to  opacity  of  that  organ,  which  disappears  after  a 
time  in  most  cases.  It  is  also  liable  to  produce  iritis  in  such  instances 
from  an  extension  of  the  corneal  inflammation  to  the  subjacent  tissues  or 
from  the  presence  of  the  eruption  upon  the  iris.  Quite  a  number  of 
cases  have  been  reported  which  appeared  to  indicate  the  direct  depen- 
dence of  glaucoma  upon  neuralgia  of  the  trigeminus.  Irritation  of  the  fifth 
nerve  has  been  known  to  produce  increased  tension  of  the  eyeball. 
But  this  question  appears  to  be  still  unsettled,  and  it  remains  for  further 
investigations  by  ophthalmalogists  to  decide  this  mooted  point.  In  one  in- 
teresting and  rare  variety  of  ophthalmic  neuralgia,  the  pain  is  strictly 
confined  to  the  interior  of  the  eyeball,  and  is  of  a  tensive  boring  charac- 
ter.    This  is  usually  looked  upon  as  a  neuralgia  of  the  ciliary  nerves; 


124  FUNCTIONAL    NEEVOrrS    DISEASES. 

sooner  or  later   it  is  generally   combined  with   neuralgia  of  some  other 
branch  of  the  trigeminus. 

In  neuralgia  of  the  superior  and  inferior  maxillarj'-  branches,  the  vaso- 
motor complications  are  most  marked.  The  face  is  red  and  hot,  and  per- 
spires profusely,  and  the  carotid  throbs  violently.  The  secretion  from 
the  nose  on  the  affected  side  is  usually  increased,  and  in  one  case,  I  saw 
it  assume  a  sero-purulent  character  during  the  continuance  of  the  pain,  i 
The  tongue  may  be  furred  on  the  painful  side,  and  the  buccal  secretions 
increased  in  amount.  The  skin  of  the  cfieek  is  sometimes  thinned  and 
shining  in  chronic  cases;  it  is  in  this  region,  also,  that  I  observed  the  hy- 
pertrophy of  the  integument  and  subcutaneous  cellular  tissue  in  the  case 
mentioned  in  the  general  remarks  on  neuralgia. 

Gross  has  described  a  peculiar  form  of  neuralgia  affecting  these  two 
branches  in  old,  toothless  people.  He  attributes  it  to  the  compression 
of  the  terminal  filaments  of  the  dental  nerves  by  the  deposit  of  newly 
formed  osseous  tissue  in  the  cavities  of  the  alveolar  processes. 

Reflex  amaurosis  has  also  been  attributed  to  neuralgia  of  the  dental 
nerves,  but  this  statement  needs  verification  before  being  fully  accepted. 

The  duration  of  trigeminal  neuralgia  frequently  depends  upon  our 
ability  to  remove  its  cause.  When  the  neuralgia  develops  after  the  age 
of  fifty,  or  in  consequence  of  irremediable  organic  changes,  the  patients 
are  very  liable  to  suffer  from  ever-increasing  pain  until  death  puts  an 
end  to  their  tortures.  The  patients  (even  those  suffering  from  the  se- 
verer forms)  may  retain  an  appearance  of  health  for  a  long  time,  but 
sooner  or  later,  the  continuous  depressing  influence  of  the  pain  and  the 
insufficient  nutrition  of  the  body  caused  by  their  fear  of  taking  food, 
lead  to  progressive  emaciation,  and  sometimes  to  a  markedly  hN'sterical 
frame  of  mind.  Such  patients  lose  their  power  of  will,  their  judgment 
becomes  impaired,  and  tlie  emotional  nature  is  unduly  excited.  A  ref- 
erence to  their  ailment  is  sometimes  sufficient  to  cause  them  to  weep 
profusely.  They  become  unable  to  attend  to  business,  not  so  much  on 
account  of  the  pain  (some  patients  are  able  to  go  through  their  usual  occu- 
pations while  suffering  terrible  tortures,  and  without  manifesting  their 
affliction  to  those  around  them),  but  rather  from  peevishness  and  inabil- 
ity to  direct  their  minds  to  any  subject  requiring  careful  thought  and  at- 
tention. Blandford  has  observed  one  form  of  neuralgia  which  alternates 
with  attacks  of  insanity. 

Etiology. 

S^ex. — In  my  own  experience,  the  female  sex  has  suffered  twice  as 
often  as  the  male;  among  107  patients,  71  were  females  and  36  males. 
We  should  also  take  into  consideration  that  I  have  not  included,  in  this 
number,  any  cases  of  hysterical  clavus  or  of  migraine,  which  are  re- 
garded by  some  writers  as  neuralgic  in  character,  and  which  are  almost 
exclusively  met  with  in  females.  This  preponderance  on  the  part  of  the 
female  sex  is  probably  due  in  great  measure  to  the  influence  of  the  child- 
bearing  period,  and  of  the  menopause. 

Afje. — More  than  half  of  my  cases  developed  between  the  ages  of 
twenty  to  forty  years,  or  that  period  at  which  the  struggle  for  life  is 
most  severe,  and  in  which  the  nervous  system  is  accordingly  subjected  to 
the  greatest  amount  of  wear  and  tear,  in  which  the  males  are  engrossed 
in  the  cares  of  business,  and  are  pressed  by  their  competitors  in  the  race 
for  a  subsistence,  and  the  females  are  compelled  to  devote  themselves  to 


NEURALGIA.  125 

the  claims  of  society,  or,  in  the  poorer  classes,  to  the  earning  of  their 
daily  bread,  in  addition  to  the  manifold  duties  of  maternity. 

Heredity. — Though  I  have,  unfortunately,  no  statistics  in  this  respect, 
my  ex})erience  has  been  that  an  hereditary  influence  is  exercised  more 
frequently  in  the  development  of  trigeminal  than  of  any  other  form  of 
neuralg-ia.  This  is,  no  doubt,  due  to  the  fact  that  the  brain  (which  con- 
tains tlie  nucleus  of  origin  of  the  fifth  nerve)  is  more  frequently  the  site 
of  disturbance  on  account  of  bad  hereditary  influences  than  the  spinal 
cord,  from  which  the  sensory  nerves  of  the  body  originate.  An  acquired 
neuropathic  disposition  may,  of  course,  also  lead  to  the  development  of 
trigeminal  neuralgia,  but  we  have  discussed  this  subject  with  sufficient 
fulness  in  our  general  remarks  on  etiology. 

Ancemia^  etc. — Trigeminal  neuralgia  develops,  in  numerous  individuals, 
as  soon  as  the  general  condition  is  somewhat  below  par,  whatever  the  cause 
of  this  deterioration  of  health  may  be.  Thus,  it  may  be  caused  by  anosmia 
from  direct  loss  of  blood,  profuse  discharges,  etc.,  by  cachexise  of  various 
kinds  (tuberculosis,  carcinoma,  etc.),  or  by  overwork.  Mental  overwork 
is  especially  effective  in  this  respect,  and  is  much  more  likely  to  produce 
neuralgia  when  the  patient  is  continually  worrying  or  fretting.  One 
of  my  friends,  who  suffers  occasionally  from  slight  neuralgic  attacks  due 
to  this  cause,  finds  that  the  pain  disappears  if  he  takes  a  hearty  meal. 
Sexual  excesses  are  also  injurious,  and  very  frequently  act  as  an  exciting 
cause. 

Reflex  causes. — A  source  of  irritation  situated  in  the  most  remote 
parts  of  the  body  may  act  as  the  exciting  cause  of  this  form  of  neuralgia. 
One  of  the  most  important  causes  in  this  category  is  straining  the 
eyes,  though,  as  we  have  previously  stated,  we  are  of  the  opinion  that 
the  frequency  of  this  factor  is  overestimated,  because  a  clear  distinction 
is  not  usually  made  between  trigeminal  neuralgia  and  other  forms  of 
headache.  Functional  abuse  of  the  eyes  usually  leads  to  supraorbital  or 
to  ciliary  neuralgias. 

Disorders  of  the  genital  organs  and  of  the  intestinal  tract  may  also  be 
included  among  these  causes.  In  one  case  I  found  that  a  severe  attack 
of  trigeminal  and  occipital  neuralgia  was  caused  by  the  presence  of  a  tape- 
worm in  the  intestines,  and  that  the  pain  disappeared  after  the  expulsion 
of  the  latter.  But  cases  of  this  nature  are  so  infrequent  that  we  are 
compelled  to  admit  the  pre-existence  of  a  neuropathic  disposition  in  such 
individuals. 

Organic  lesions. — In  the  cranial  cavity  there  are  several  conditions 
which  may  act  as  causes  of  trigeminal  neuralgia.  Romberg  reported  the 
"Well-known  case  in  which  the  autopsy  showed  that  an  aneurism  of  the  in- 
ternal carotid  had  pressed  upon  the  Gasserian  ganglion  and  the  origin 
of  the  trigeminus,  and  had  thus  given  rise  to  intense  neuralgia  of  many 
years'  duration.  Other  tumors  at  the  base  of  the  brain  (carcinoma,  syphi- 
loma, cholesteotoma,  etc.),  may  act  in  a  similar  manner.  Exostoses  grow- 
ing from  the  petrous  portion  of  the  temporal  bone  and  periostitis  of  this 
part  should  be  included  in  the  same  category.  In  the  peripheral  course 
of  th'fe  nerves,  they  may  be  irritated  by  tumors  growing  from  adjacent 
parts  of  the  face,  by  wounds  of  various  kinds,  the  presence  of  foreign 
bodies,  the  spread  of  inflammation  from  middle  ear  troubles,  dental  caries 
or  exostoses  of  the  alveolar  processes. 

Constitutional  causes. — Malaria  and  syphilis  are  the  only  general  dis- 
eases which  have  an  undoubted  influence  upon  the  production  of  this  form 
of  neuralgia.     Malaria  is  a  very  important  factor,  and  usually  gives  rise 


126  FUNCTIONAL    NERYOUS    DISEASES. 

to  supra-orbital  neuralgia,  though  in  rare  oases  it  may  produce  pain  in 
the  distribution  of  all  the  branches  of  the  trigeminus.  This  variety  is 
easily  detected  by  its  periodicity  and  ready  amenability  to  treatment  by 
quinine,  or,  in  chronic  cases,  by  arsenic. 

Syphilis  may  give  rise  to  neuralgia  either  during  the  secondary  or  ter- 
tiary stage.  The  former  variety  is  extremely  rare,  and  no  cases  have 
come  under  my  own  notice.  The  latter  form  is  more  common,  and  is  due 
to  gummatous  infiltration  of  the  nerves  or  their  neurilemma,  or  to  com- 
pression of  the  nerves  by  gummy  growths.  But  even  this  la.tter  form  is 
not  so  frequent  as  is  generally  supposed,  and  the  mistake  undoubtedly 
arises  from  the  fact  that  osteocopic  pains  are  often  regarded  as  neural- 
gic in  character. 

Cold. — Sudden  checking  of  perspiration  from  exposure  to  a  draught, 
etc.,  has  been  regarded  as  a  frequent  cause  of  trigeminal  neuralgia,  though 
the  modus  operandi  of  its  action  is  very  obscure.  There  is  no  doubt,  how- 
ever, that  it  sometimes  acts  as  an  excit'ng  cause  ;  we  also  find  in  cases  of 
this  kind  that  considerable  relief  is  often  obtained  by  the  application  of 
warmth  and  diaphoresis. 

A  considerable  contingent  of  cases  remains,  however,  in  which  no 
cause  is  ascertainable,  in  which  we  must  remain  satisfied  with  the 
bare  diagnosis  of  neuralgia,  and  in  which  merely  symptomatic  treatment 
is  therefore  admissible. 


Diagnosis  akd  Peogkosis. 

The  headache  of  ancBinia  is  often  mistaken  for  neuralgia,  but  it  can 
be  readily  differentiated.  The  pain  of  anaemia  is  not  confined  to  the 
course  of  the  nerves,  but  is  diffused  over  the  forehead  or  the  entire  vertex. 
It  is  of  a  dull  or  lifting  tensive  character,  and  is  continuous,  never  par- 
oxysmal. The  temperature  of  the  scalp  is  sometimes  raised  very  appre- 
ciably, and  the  integument  may  be  acutely  hyperEesthetic. 

Migraine  (hemicrania)  has  been  regarded  by  many  authorities  as  a 
form  of  neuralgia,  but  it  is  now  almost  universally  considered  to  be  a 
neurosis  of  the  sympathetic  nerve.  The  d  fferential  diag-nosis  between 
migraine  and  trigeminal  neuralgia  is  usually  effected  with  great  readiness. 
While  neuralgia  is  rarely  observed  before  the  age  of  twenty,  migraine 
generally  begins  about  the  period  of  puberty,  and  sometimes  even  much 
earlier.  Furthermore,  heredity  plaj^s  a  much  more  important  part  in  the 
etiology  of  migraine  than  it  does  in  that  of  neuralgia.  The  pain  also 
presents  entirely  different  characteristics.  In  migraine  it  is  of  a  throb- 
bing, dull  character,  and,  unlike  that  of  neuralgia,  is  felt  deep  within  the 
skull,  and  not  in  the  distribution  of  special  nerves.  Migraine  is  also 
sometimes  accompanied  by  hyperjethesia  of  the  auditory  and  optic  nerves, 
and  also  by  hallucinations  of  these  two  senses.  The  course  pursued  by 
the  tv.'o  affections  is  entirely  different.  An  attack  of  migraine  rarely 
lasts  more  than  twenty-four  hours,  and  the  patient  is  then  free  from 
suffering  until  another  attack  occurs.  We  must  not  forget,  however,  that 
the  two  affections  may  be  combined  in  the  same  patient. 

Claviis  hystericvs. — This  is  a  fixed  pain,  situated  in  the  parietal  region 
near  the  sagittal  suture  ;  the  suffering  has  been  likened  to  that  produced 
by  driving  a  nail  into  the  scalp.  It  is  always  combined  with  other  well- 
known  symptoms  of  hysteria.  These  characteristics  are  sufficient  to 
differentiate  it  from  triireminal  neurala'ia. 


NEURALGIA.  127 

Osteocopic  pains. — These  are  also  frequently  mistaken  for  true  neu- 
ralgia, when  they  occur  in  the  forehead.  They  usually  make  their  ap- 
pearance durini^  the  secondary  stage  of  syphilis,  and  almost  always  occur 
at  night;  they  are  confined  to  one  spot,  and  are  sometimes  excruciating, 
"  as  if  the  bones  were  being  split."  They  readily  recover  under  the  use 
of  mercurials. 

Headache  of  JtrlgJii's  disease. — Although  the  diagnosis  between 
this  condition  and  trigeminal  neuralgia  is  ajjparently  very  easy,  never- 
theless mistakes  sometimes  occur.  Within  the  last  six  months,  two 
grave  errors  of  this  kind  have  come  under  my  notice.  In  one  case  the 
patient  had  been  treated  for  upward  of  two  years  for  neuralgia.  The 
character  of  the  pain  alone  should  have  led  to  a  suspicion  of  serious 
organic  trouble;  it  was  bilateral,  of  a  dull,  continuous  character  (lasting 
day  and  night),  and  attended  with  frequent  attacks  of  vomiting.  An 
examination  of  the  patient's  heart  revealed  the  existence  of  hypertrophy 
of  the  left  ventricle  without  valvular  lesion.  Suspicion  was  therefore 
directed  to  the  kidneys,  and  an  examination  of  the  urine  showed  a  low 
specific  gravity,  and  the  presence  of  a  very  large  amount  of  albumen. 
The  diagnosis  of  Bright's  disease  was  therefore  evident. 

The  various  conditions  which  we  have  enumerated  above  are  frequent- 
ly mistaken  for  neuralgia.  Such  an  error  is  chiefly  attributable  to  the 
loose  manner  in  which  the  term  neuralgia  is  employed  by  the  profession. 
If  we  bear  in  mind  the  distinguishing  characteristics  of  neuralgic  pain  to 
which  we  have  referred  in  the  general  remarks  on  diagnosis,  the  differen- 
tiation from  other  painful  affections  will  be  readily  made  iu  almost  all 
cases. 

Prognosis. — This  depends  in  great  part  upon  the  etiology.  If  the 
neuralgia  is  due  to  malaria,  syphilis,  exposure,  ana?mia,  or  overwork,  the 
attack  will  soon  subside,  as  a  rule,  when  we  are  in  a  position  to  successfully 
combat  the  primary  cause.  The  prognosis  is  also  very  favorable  when 
the  neuralgia  is  reflex  in  its  nature.  A  great  many  of  the  so-called 
idiopathic  cases,  however,  especially  those  which  Vjegin  late  in  life,  and 
those  which  are  due  to  anatomical  lesions  of  the  nerves,  are  very  obstinate 
in  their  nature,  resisting  all  medical  treatment,  and  sometimes  even  surgi- 
cal interference  (neurotomy,  etc.).  A  large  proportion,  also,  of  those 
cases  which  are  due  to  hereditary  influence,  present  a  gloomy  prognosis 
as  regards  complete  recovery.  Although  such  an  attack  of  neuralgia 
may,  perhaps,  yield  readily  to  treatment,  nevertheless  there  is  great 
liability  to  relapse,  whenever  the  tone  of  the  nervous  system  is  lowered 
from  any  cause,  such  as  mental  overwork,  sexual  or  alcoholic  excesses, 
etc.  But,  on  the  whole,  trigeminal  neuralgia  is  not  such  a  bugbear  as  it 
is  generally  regarded,  and  there  are  numerous  measures  at  our  command, 
which,  if  they  will  not  cure,  will  at  least  produce  decided  relief  in  most 
cases,  and  there  are  very  few  in  which  life  cannot  be  made  tolerable  to 
the  sufferers. 

Treatmext. 

The  remarks  which  have  been  made  on  page  112  et  seq.  will  also  apply  to 
the  treatment  of  trigeminal  neuralgia,  but  there  are  some  special  points  to 
which  we  desire  to  call  attention.  In  the  first  place,  severe  cases  de- 
mand entire  mental  rest,  especially  when  the  patient  has  a  bad  family 
history.  If  there  are  any  evidences  of  serious  hereditary  neuroses, 
especially  if  there  has  been  any  insanity  in  the  family,  we  must  regard 


128  FUNCTIONAL    NEEVOUS   DISEASES. 

the  patient  with  suspicion.  If  he  is  engrossed  in  the  cares  and  anxie- 
ties of  business,  he  should,  for  a  time,  give  up  his  occupation  when  tliia 
plan  is  practicable.  Physical  rest  should  also  be  obtained.  The  exercise 
allowed  the  patient  must  at  first  be  of  a  mild  character  (walking,  car- 
riage-riding, fishing,  etc.).  He  must  be  especially  warned  against  the 
dangers  of  sexual  excesses,  and  it  is  perhaps  advisable  to  counsel  abso- 
lute continence  until  the  patient  has  entirely  recovered  from  the  neu- 
ralgia. 

The  diet  should  be  varied  and  plentiful,  and  the  appetite  stimulated  in 
every  possible  way.  Unfortunately  the  movements  of  mastication  will 
frequently  give  rise  to  the  development  of  a  paroxysm  of  pain,  and  the 
nutrition  of  the  patient  is  thus  seriously  interfered  with.  We  must 
then  place  our  chief  reliance  on  a  milk  diet.  In  those  unfortunate  cases 
in  which  the  pain  produced  during  eating  is  so  excruciating  that  the 
patients  will  only  take  very  minute  quantities  of  food  at  a  time,  we 
should,  without  much  delay,  begin  to  nourish  the  patient  by  means  of 
rectal  alimentation.  This  is  especially  important  because  the  severe 
cases  to  which  we  now  refer  usually  occur  in  old  age,  and  the  vital 
powers  are  therefore  in  danger  of  sinking  from  the  combined  depressing 
influences  of  the  terrible  pains  and  the  insufficient  amount  of  nourish- 
ment. 

In  protracted  cases  the  condition  of  the  eyes  should  always  be  care- 
fully examined,  and  if  it  is  found  necessary,  reading  (especially  news- 
papers) should  be  entirely  interdicted. 

Other  reflex  sources  of  irritation  must  be  carefully  inquired  into. 
The  condition  of  the  genital  organs  and  of  the  intestinal  tract  should 
also  be  investigated.  We  must,  however,  advise  caution  in  respect  to 
the  habit  of  indiscriminately  pulling  out  carious  teeth  (sometimes  even 
sound  ones)  when  a  patient  suffers  from  a  severe  attack  of  neuralgia.  In 
bad  cases  this  is  sometimes  carried  so  far  that  all  the  teeth  are  removed 
from  one  side  of  the  jaw,  the  patient,  in  the  meanwhile,  growing  steadily 
worse.  It  is  to  be  remembered  that  the  teeth  are  essential  factors  in  the 
process  of  digestion,  and  that  they  should,  therefore,  not  be  sacrificed 
unwarrantably.  They  should  not  be  extracted  until  we  have  made  a  care- 
ful search  for  other  causes,  and  unless  manipulation  of  the  supposed 
offending  tooth  produces  a  decided  increase  of  pain. 

In  that  form  of  neuralgia  known  as  neuralgia  of  the  jaw-bones,  which 
was  first  described •  by  Gross  (and  which  he  attributed  "to  the  com- 
pression of  the  minute  nerves  distributed  through  the  wasted  alveolar 
processes,  dependent  on  the  encroachment  of  osseous  matter  upon  the 
walls  of  the  canals  in  which  they  are  enclosed  "),  this  distinguished  sur- 
geon obtained  admirable  results  by  resecting  the  affected  part  of  tlia 
alveolar  process.  A  succinct  account  of  the  operation  is  given  in  the 
American  Journ.  of  Med.  Sciences,  for  1870. 

Trigeminal  neuralgia,  due  to  malaria,  must  be  treated,  of  course,  like 
all  other  manifestations  of  this  disease,  with  large  doses  of  quinine.  The 
best  plan  is  to  slightly  cinchonize  the  patient  for  two  or  three  days,  and 
then  continue  the  remedy  for  a  couple  o.f  weeks  in  tonic  doses.  This 
variety  presents  a  very  great  tendency  to  relapse  whenever  the  system  is 
subjected  to  malarial  influences. 

The  syphilitic  forms  of  this  neuralgia  are  treated  with  mercurials  and 
iodide  of  potassium  respectively,  according  as  they  appear  in  the  secon- 
dary or  tertiary  stages.  We  must  repeat,  even  at  the  risk  of  appearing 
tiresome,  that  these  remedies  must  not  be  discontinued  as  soon  as  the 


NEURALGIA.  129 

neuralgia  has  disappeared,  but  should  bo  administered  for  a  long  time 
afterward. 

Syphilitic  neuralgias  are  very  frequently  the  forerunners  of  more 
serious  nervous  affections,  which  can,  in  such  cases,  only  be  forestalled  by 
persevering,  long-continued  anti-syphilitic  medication.  We  should  also 
Avarn  these  patients  against  the  dangers  of  alcoholic  excesses.  One  of  the 
severest  forms  of  cerebral  syphilis  is  that  due  to  changes  in  the  coats  of 
the  blood-vessels,  and  these  would  only  be  aggravated  by  excessive  in- 
dulgence in  stimulants. 

In  other  forms  of  trigeminal  neuralgia  resort  is  had  to  the  use  of  nar- 
cotics or  so-called  specifics. 

In  my  own  practice  I  have  learned  to  dispense  with  narcotics  to  re- 
lieve trigeminal  neuralgia,  until  other  remedies  have  failed  me.  It  is  to 
be  remembered  that  this  form  of  neuralgia  is  especially  apt  to  be  long- 
continued,  that  in  such  cases  the  opium  habit  is  very  liable  to  be  estab- 
lished (especially  because  we  must  employ  the  hypodermic  method  of 
administration),  and  that  when  this  has  once  developed,  an  attempt  to 
diminish  the  quantity  of  morphine  injected  will  almost  inevitably  lead  to 
a  decided  increase  in  the  intensity  of  the  pain.  This  is  not  an  imaginary 
evil,  as  the  majority,  perhaps,  of  the  cases  of  chronic  opium-eating  which 
have  fallen  under  my  notice,  have  been  due  to  the  administration  of  opium 
begun  in  this  very  disease. 

But  when  we  have  determined  to  use  opium  (the  best  method  of  ad- 
ministration is  the  hypodermic  injection  of  Magendie's  solution)  we  should 
always  bear  in  mind  that  our  object  is  to  relieve  the  pain  as  rapidly  as 
possible.  It  is  much  better  to  give  a  single  large  dose  than  a  couple  of 
smaller,  insufficient  ones;  by  the  latter  method  an  equally  large  amount  of 
opium  may  enter  the  system  without  producing  the  desired  effect.  It  is 
impossible  to  state  in  so  many  words  what  dose  is  requisite,  since  this  de- 
pends entirely  upon  the  severity  of  the  pain,  and  the  individual  suscepti- 
bility of  the  patient.  In  exceptional  cases,  opium  appears  to  have  not 
only  a  palliative,  but  also  a  markedly  curative  effect.  It  is  sometimes  found 
that  the  patient  remains  permanently  free  from  the  pain,  as  soon  as  the 
latter  has  been  entirely  relieved  through  the  use  of  a  full  dose  of  the  drug. 
In  those  cases  (and  unfortunately  they  are  very  frequent)  in  which  narco- 
tics must  be  employed  for  a  long  time,  the  use  of  morphine  may  be  alter- 
nated from  time  to  time  with  hypodermics  of  atropine  or  of  pure  water, 
whenever  either  of  these  agents  is  found  serviceable.  In  this  manner  we 
can  avoid  accustoming  the  system  to  the  administration  of  morphine,  and 
can  thus  restrict  the  quantity  exhibited  to  the  lowest  possible  amount. 
Morphine  or  atropine  should  never  be  injected  into  the  face,  because  thev 
produce  no  better  effect  when  administered  in  this  manner  than  when  in- 
jected at  a  distance,  and  furthermore,  abscesses  develop  at  the  site  of  in- 
jection in  exceptional  cases,  and  might  thus  lead  to  deformity.  Bartholow 
also  recommends  aquapuncture  for  its  palliative  effects,  thirty  to  sixty 
drops  being  injected,  and  the  operation  repeated  in  two  minutes  if  not  suc- 
cessful. 

In  aconitia  we  possess  a  remedy  which  appears  to  single  out  trigem- 
inal neuralgia  for  the  display  of  its  curative  properties.  The  initial  dose 
of  this  remedy  is  gr.  y-|-(J-,  t.i.d.,  and  increased  by  a  single  dose  daih- 
until  its  physiological  effects  are  produced.  The  drug  is  now  prepared 
in  the  form  of  granules,  but  we  do  not  favor  its  exhibition  in  this  shape, 
because  we  cannot  graduate  the  dose  as  carefully  as  is  desirable  in  dealing 
with  such  a  virulent  poison.  This  remedy  has  produced  recovery  in  a  case 
9 


130  FUNCTIONAL    NERVOUS    DISEASES. 

in  which  all  three  branches  of  the  trigeminus  had  been  unsuccessfully  ex- 
cised, and  I  have  also  seen  a  patient  in  whom  it  produced  relief  after  an 
unsuccessful  excision  of  the  inferior  dental  nerve  had  been  made.  In  a 
certain  proportion  of  cases,  however,  it  fails  us  entirely,  whereas  it  may 
produce  a  perfect  success  in  other  and  apparently  similar  ones.  But 
aconitia  has  already  proved  a  very  valuable  addition  to  our  anti-neuralgic 
remedies,  and  after  the  enthusiam  of  some  observers  has  been  moderated, 
and  the  indications  with  regard  to  its  use  have  been  more  clearly  defined, 
it  will  assume  its  position  as,  perhaps,  one  of  our  best  remedies  for  the 
disease  under  consideration. 

Arsenic,  in  the  form  of  Fowlers  solution,  is  also  a  valuable  agent. 
We  have  previously  referred  (page  118)  to  the  manner  in  which  it  should 
be  administered.  This  drug  appears  to  be  especially  indicated  in  the 
severe  and  obstinate  cases  developing  in  old  age,  and  we  have  sometimes 
been  surprised  to  see  what  marked  and  rapid  improvement  will  occur  in 
some  which  were  apparently  hopeless.  xVrsenic  does  not  appear  to  me  to 
act  directh'  upon  tlie  neuralgic  affection,  but  rather  by  giving  tone  to  the 
general  nervous  system.  I  have  arrived  at  such  a  conclusion  from  the 
fact  that  it  is  an  invaluable  agent  in  all  neuroses  due  to  nervous  exhaus- 
tion or  in  which  the  nutrition  of  the  nervous  S3'stem  is  impaired  in  old 
age. 

Gelsemium  sempervirens  is  especially  reliable  in  dental  neuralgias,  but 
is  also  useful  in  a  considerable  number  of  other  varieties  of  facial  neural- 
gia. Tliis  should  also  be  given  until  slight  toxic  effects  become  noticea- 
ble, the  initial  dose  varying  from  live  to  ten  drops  of  the  fluid  extract. 
It  is  often  difficult  to  obtain  a  reliable  preparation. 

Strychnia  has  also  been  employed  in  this  affection,  but  I  cannot  recom- 
mend it  very  highly,  and,  at  present,  I  only  use  it  after  having  made  an 
unsuccessful  trial  of  the  drugs  previousl}^  mentioned.  My  experience 
with  it  has  been  so  unsatisfactory  that  I  am  gradually  abandoning  its  use 
in  this  disease. 

Whenever  the  affection  is  attended  with  tenderness  of  the  first  or 
second  cervical  vertebras  iypoint  apophysaire)  it  is  advisable  to  employ 
counter-irritation  over  the  tender  spot  (either  with  a  fly-blister  or  with 
the  electrical  wire  brush)  in  combination  with  some  of  the  remedies  which 
we  have  just  mentioned.  Counter-irritation,  under  these  conditions, 
almost  always  produces  a  certain  amount  of  relief. 

The  employment  of  the  faradic  current  is  not  only  devoid  of  advan- 
tage in  this  affection,  but,  on  the  contrary,  I  have  seen  a  single  applica- 
tion of  this  form  of  electricity  convert  a  mild  case  into  an  extremely 
severe  one.  The  galvanic  current  is  not  open  to  this  criticism,  but  its  use 
is  attended  with  fewer  successes  in  this  tlian  in  any  other  form  of  neural- 
gia. In  applying  it,  one  electrode  should  be  placed  upon  the  nape  of 
the  neck,  and  the  other  over  the  exit  of  the  branches  of  the  nerve  from 
their  bony  canals  under  the  integument  of  the  face.  The  current  should 
only  be  employed  continuously,  and,  in  cases  in  which  we  suspect  a  cen- 
tral origin,  we  may  place  both  electrodes  over  the  mastoid  processes,  and 
allow  a  current  to  pass  through  the  brain.  As  soon  as  the  patient  becomes 
dizzy  the  application  is  discontinued,  and  a  weaker  current  employed. 
We  must  be  careful  to  use  only  mild  currents  upon  the  face,  and  their  in- 
tensity should  be  increased  very  graduall}'  and  cautiously.  The  applica- 
tions may  last  from  five  to  ten  minutes,  and  are  repeated  daily  or  every 
other  day.  ^  * 

When  internal  medication  or  the  use  of  galvanism,  etc.,  prove  useless, 


NEURALGIA.  131 

we  are  compelled  to  fall  back  upon  surgical  interference  as  a  dernier  res- 
sort.  In  no  other  form  of  neuralgia  has  this  mode  of  treatment  been  more 
frequently  or  more  successfully  employed.  Recourse  may  be  had  to  neu- 
rotomy, neurectomy,  nerve-stretching  or  ligature  of  the  carotid.  The 
operation  of  neurotomy  is  very  simple  (it  can  be  done  subcutaneously 
without  even  disfiguring  the  patient),  but  it  is  usually  barren  of  results  on 
account  of  the  ready  reunion  of  the  divided  ends  of  the  nerves.  Neurec- 
tomy is  the  operation  generally  resorted  to,  and  portions  of  the  nerves  have 
been  excised  in  every  part  of  their  course,  the  daring  knife  of  the  sur- 
eeon  enterino-  even  as  far  back  as  the  foramen  rotundum  at  the  base  of 
the  skull. 

Dr.  Dennis,  who  has  lately  reviewed  the  subject  of  neurotomy  '  as 
applied  to  the  superior  maxillary  nerve,  thinks  that  the  operation  offers 
the  best  chances  of  success  when  the  excision  is  made  between  the 
spheno-palatine  ganglion  and  the  foramen  rotundum.  There  can  be  no 
djjubt,  even  from  the  n  erel}^  cursory  review  which  we  have  made  of  the 
surgical  literature  of  the  subject,  that  this  operation  (which  is  the  most 
difficult  and  dangerous  of  all  the  operations  for  neurectomy  of  the 
trigeminus),  is  steadily  gaining  favor  among  practical  surgeons.  We 
must  refer  the  reader  to  surgical  treatises  for  a  description  of  the  modus 
operandi  of  these  operations.  Some  of  them,  such  as  excision  of  a 
portion  of  the  inferior  dental  nerve  (while  in  the  canal)  are  of  a  very 
simple  nature,  and  may  be  performed  without  the  possession  of  special 
surgical  training. 

Nerve-stretching  has  also  been  resorted  to  within  the  last  few  years, 
in  cases  of  trigeminal  neuralgia,  and  this  method  can  already  point  to 
some  successes.  The  operation  has  been  performed  upon  all  three 
branches  of  the  nerve,  and  is  stated  to'  be  of  service  even  when  the 
neuralgia  has  a  central  origin.  It  should  be  done  cautiously,  and  the 
nerve  not  pulled  upon  too  strongly.  It  is  reserved  for  future  investiga- 
tions to  determine  the  special  indications  for  nerve-stretching  and  neu- 
rectomy in  this  form  of  neuralgia,  and  their  relative  merits. 

Finally,  we  must  mention  the  opera.tion  of  ligature  of  the  carotid  for 
obstinate  cases  of  this  disease.  This  was  proposed  b}^  Nussbaum,  and 
has  been  performed  quite  frequently  by  this  and  other  German  surgeons, 
in  most  cases  with  admirable  results.  But  the  operation  can  only  be 
looked  upon  as  a  last  resort,  and  should  only  be  performed  after  medi- 
cinal agents,  netirectomy,  and  nerve-stretching  have  been  faithfully 
employed. 

Despite  the  large  number  of  cases  of  trigeminal  neuralgia  which 
have  been  operated  upon,  its  surgical  treatment  is  still  in  a  somewhat 
chaotic  condition,  and  not  until  the  surgeon  enters  more  carefully  into 
the  minute  details  of  the  affection,  will  the  indications  for  the  various 
operations  be  more  precisely  defined. 

J  New  York  Med.  Journal,  1879. 


CHAPTER  yn. 

OCCIPITAL  NEUKALGIA. 
Clinical  Histoet. 

This  term  refers  to  an  affection  of  either  the  occipitalis  major  '  or 
minor  nerves.  When  the  auricularis  magnus,  subcutaneous  colli,  or 
supra-clavicular  nerves  are  involved,  the  affection  is  known  as  cervico- 
occipital  neuralgia.  Occipital  neuralgia  is  not,  by  any  means,  a  very 
uncommon  affection,  while  cervico-occipital  neuralgia  is  extremely  rare, 
and  I  have  only  seen  it  in  combination  with  other  varieties. 

The  character  of  the  pain  is  entirely  similar  to  that  described  in 
prosopalgia,  but  it  usually  presents  a  much  less  degree  of  severity.  It 
shoots  along  the  back  of  the  head  as  far  as  the  vertex,  and  when  the 
occipitalis  minor  is  involved,  likewise  affects  the  lobe  of  the  ear.  When 
the  other  above-mentioned  nerves  are  implicated,  the  pain  darts  into  the 
lower  part  of  the  face  and  chin,  the  front  of  the  neck,  and  the  upper 
part  of  the  chest  and  shoulder  on  the  same  side.  Occipital  neuralgia  is 
much  more  commonly  bilateral  than  an}^  other  form  of  the  disease.  The 
only  painful  points  which  we  have  been  able  to  detect  are  an  occipital 
point,  a  little  to  the  outside  of  the  occipital  protuberance,  and  another, 
at  the  point  at  which  the  nerve  becomes  superficial  {between  the  occipital 
bone  and  the  first  cervical  vertebra).  A  point  apophysaire  can  be  read- 
ily detected,  in  most  cases,  over  the  second  or  third  cervical  vertebra. 
During  the  paroxysms  of  pain  the  patients  hold  the  head  and  neck  as 
immovable  as  possible,  because  a  fresh  attack  is  ver}^  readily  induced 
upon  the  slightest  movement.  It  is  important  to  remember,  however, 
that  the  head  does  not  assume  any  characteristic  position  in  this  affec- 
tion. "Occipital  neuralgia  is  attended  with  very  few  complications,  and 
the  only  one  which  I  have  ever  noticed  has  been  a  change  in  the  color  of 
a  lock  of  hair  situated  in  the  course  of  the  nerve. 

Dr.   Julius   Schreiber  **   reported    a   unique    case   of    double   occipital 

'  The  occipitalis  major  nerve  makes  its  exit  from  the  spinal  canal  between  the  first 
and  second  cervical  vertebiee,  passes  upward  and  becomes  superficial  ut  the  lower  pos- 
terior border  of  the  scalp,  very  close  to  the  median  line.  It  then  passes  uiiward  to 
supply  the  integument  as  far  as  the  vertex.  The  occipitalis  minor  nerve  is  a  branch 
of  the  third  cervical,  escapes  behind  the  sterno-mastoid  muscle,  upon  which  it  ascends 
to  the  occiput  half-way  between  the  lobe  of  the  ear  and  the  median  line.  It  supplies 
the  integument  of  the  lateral  portion  of  the  occiput,  and  sometimes  the  median  sur- 
face of  the  ear.  The  auricularis  magnus  is  a  branch  of  the  third  cervical,  and  sup- 
plies the  integument  of  the  mastoid  process  of  the  concha  ot  the  ear  and  the  external 
auditory  canal.  The  subcutaneous  colli  is  also  a  branch  of  the  third  cervical,  and 
supplies  the  integument  of  the  upper  part  of  the  neck  and  under  surface  of  the 
chin.  The  supra-clavicular  nerves  arise  chiefly  from  the  fourth  cervical,  and  pass 
downward  to  supply  the  lower  part  of  the  neck  and  the  upper  parb  of  the  thorax. 

^Berl.  kl.  Wschr.,  1877,  p.  726. 


NEURALGIA.  133 

neuralgia,  due  to  malaria,  in  which  vaso-motor  and  secretory  disturbances 
appeared  in  the  course  of  the  trigeminus.  These  complications  consisted 
of  redness  of  the  face,  injection  of  the  conjunctiva,  a  profuse  discharge 
of  tears,  increase  in  the  nasal  secretion,  and  sneezing.  The  patient  was 
relieved  by  large  doses  of  quinine. 

Occipital  neuralgia  is  not  infrequently  combined  with  trigeminal, 
sometimes  one  form  being  more  severe,  sometimes  the  other.  This  com- 
bination occurred  in  eleven  cases  under  my  observation.  The  pain  of 
one  variety  rnay  be  so  predominant  that  the  patients  fail  to  mention  the 
milder  pain.  In  a  smaller  number  of  cases,  it  is  combined  not  alone  with 
trigeminal,  but  also  with  brachial  neuralgia,  and  in  these  cases  we  have 
always  found  marked  tenderness  along  several  of  the  upper  cervical 
vertebrae. 

Etiology. 

In  my  own  cases  I  have  found  no  especial  difference  with  regard  to 
sex,  the  cases  being  distributed  almost  equally  among  both,  although  the 
females  are  slightly  in  the  preponderance.  Some  authors  have  had  a  dif- 
ferent experience,  however,  and  Eulenburg  states  that  the  proportion  of 
females  to  males  is  as  five  to  one. 

The  disease  chiefly  affects  adult  life,  the  youngest  of  my  patients  be- 
ing twenty-five  years  old,  and  the  oldest  seventy-six  years.  The  majority 
vary  from  twenty-five  to  fifty-five  years,  only  two  of  my  patients  being 
above  the  latter  age. 

The  chief  exciting  cause  appears  to  be  exposure,  and  this  is  readily 
understood,  as  the  back  of  the  neck  is  peculiarly  liable  to  these  influences. 
The  patients  are  also  very  liable  to  relapses  from  renewed  exposure  to 
such  causes. 

Spondylitis  deformans  is  also  a  not  infrequent  cause  of  the  affection. 
Special  attention  was  called  to  this  process  by  Dr.  Julius  Braun  in  a 
pamphlet  which  he  published  upon  the  subject  several  years  ago.'  It 
consists  of  a  chronic  inflammation  of  the  ligaments  and  osseous  tissues  of 
the  vertebrae  (chiefly  the  lateral  processes),  attended  with  enlargement 
and  deformity  of  the  bones,  and  with  marked  tenderness  of  the  affected 
tissues.  Although  Braun  entertains  exaggerated  views  concerning  the 
frequency  and  importance  of  spondylitis  deformans,  we  think  it  acts  more 
frequently  as  a  cause  of  occipital  and  brachial  neuralgias  than  has  been 
hitherto  supposed.  I  can  frankly  state  that  I  have  probably  overlooked 
this  process  in  more  than  one  instance  prior  to  the  appearance  of 
Braun's  article,  and  the  affection  is  scarcely  mentioned  either  by  ortho- 
pedic surgeons  or  by  neurologists. 

In  rare  instances  occipital  neuralgia  may  be  due  to  various  other 
causes.  Thus,  it  may  arise  from  syphilis,  malaria,  caries  of  the  first  or 
second  cervical  vertebra;,  tumors  of  the  spinal  cord  pressing  upon  the 
nerves  at  their  exit  from  the  canal,  direct  injury  from  blows,  or  the  pres- 
ence of  a  carious  tooth.  Heredity  exercises  little  influence  upon  its  pro- 
duction, the  only  case  of  this  nature  with  which  I  am  acquainted  being 
mentioned  by  Anstie;  but  even  in  this  patient,  brain-work  and  exposure 
are  mentioned  as  the  exciting  causes. 

In  those  cases  which  are  combined  with  brachial  neuralgia  I  have 
long  thought  that  the  disease  was  probably  symptomatic  of  a  subacute 

'  Klin.  u.  Anat.  Beitraege  z,  Kentniss  d.  Spondylitis  Deformans. 


134  FUNCTIONAL    NEKVOUS    DISEASES. 

mening'itis  of  the  posterior  portion  of  the  cervical  cord.  My  opinion  is 
based  on  tlie  fact  that  the  pain,  in  such  cases,  is  not  infrequently  bilat- 
eral (radiating  into  both  arms  and  into  both  sides  of  the  occiput),  that 
they  are  all  attended  with  diffuse  tenderness  of  the  entire  cervical  spine,, 
and  that  the  pain  gradually  disappeared  after  the  continued  application  of 
counter-irritation  to  this  reo-ion. 


Diagnosis  and  Prognosis. 

Occipital  neuralgia  is  most  frequently  mistaken  for  myalgia  affecting 
the  muscles  at  the  back  of  the  neck,  this  region,  as  vrell  as  the  shoulders, 
being  a  favorite  site  of  muscular  rheumatism.  A  careful  observation  will 
suffice  to  discriminate  these  two  affections,  and  we  have  entered  so  fully 
(page  108)  into  the  characteristics  of  myalgic  pain,  that  it  is  unnecessary 
to  refer  to  this  subject  again. 

Caries  of  the  first  and  second  cervical  vertebrre  may  also  be  mistaken 
for  the  disease  under  consideration.  At  the  onset,  cervical  caries  may 
present  no  symptoms  beyond  those  of  occipital  neuralgia,  and  it  may, 
therefore,  be  impossible,  for  a  while,  to  diagnose  the  former  affection. 
But  even  at  this  early  period  our  suspicions  should  be  aroused  if  the  neu- 
ralgia is  bilateral,  and  resists  treatment  very  obstinately.  After  a  short 
lapse  of  time,  however,  other  symptoms  are  manifested  which  reveal  the 
true  nature  of  ^he  disease.  Whenever  the  patient  wishes  to  move  his 
head,  he  assists  himself  by  pulling  the  head  upward  with  his  hands; 
there  is  considerable  interference  with  the  rotatory  or  flexion  movements 
of  the  head.  Finally,  the  head  may  become  fixed  in  one  position,  the 
face  usually  being  directed  downward  and  to  one  side.  In  some  cases 
an  attempt  at  rotation  or  flexion  of  the  head  will  give  rise  to  a  grating 
sound,  which  is  heard  by  the  patient;  the  grating  may  also  be  palpable 
to  the  hand  when  placed  upon  the  affected  region.  Finally,  some  pa- 
tients present  evidences  of  pressure  upon  the  spinal  cord,  in  the  shape  of 
cervical  paraplegia  or  of  hemiplegia. 

Cancer  of  the  vertebrfe  may  be  also  mistaken  for  simple  neuralgias 
(occipital,  brachial,  etc.),  but  we  Avill  refer  to  this  subject  at  a  later  period. 

The  lyrognosis  of  occipital  neuralgia  is  usually  good.  The  large  ma- 
jority of  cases  recover  within  a  short  period,  though  in  a  few  exceptional 
cases  they  may  resist  the  most  active  measures  of  treatment  and  even 
surgical  interference. 


Teeatment. 

The  recognition  of  the  malarial  or  syphilitic  nature  of  the  disease  is. 
sufficient  to  indicate  to  us  the  plan  of  treatment  to  be  pursued  in  such 
cases.  When  the  neuralgia  is  due  to  spondylitis  deformans,  the  best 
treatment  consists  in  the  continued  application  of  the  compound  tincture 
of  iodine  to  the  affected  parts,  the  daily  use  of  warm  baths,  and  the  inter- 
nal administration  of  small  doses  of  the  iodide  of  potassium  (gr.  x.,  t.i.d.). 
The  patients  usually  experience  great  relief  from  such  measures,  even 
thougli  the  deformity  of  the  vertebrre  does  not  disappear.  The  actual 
cautery  may  also  be  resorted  to  in  severe  cases  of  this  kind. 

The  treatment  of  ordinary  attacks  of  occij^ital  neuralgia  is  of  a  very 
simple  nature.      Counter-irritation   furnishes  the  best   method   of   treat- 


NEURALGIA.  135 

nient.  We  may  employ  either  the  ordinary  fly -blister  (which  produces 
the  most  permanent  e.'^ects)  or  the  electrical  wire  brush;  these  should 
be  applied  directly  over  the  point  apop/iysaire.  Marked  relief  very 
seldom  fails  to  be  produced  by  these  measures,  even  in  long-standing 
cases.  In  addition,  we  may  employ  with  advantage  the  constant  gal- 
vanic current,  applied  directly  along  the  course  of  the  affected  nerve. 
When  the  pain  is  very  severe,  hypodermic  injections  of  morphine  or  atro- 
pine; are  useful,  and  I  have  sometimes  thought  that  special  benefit  is  de- 
rived froni  making  the  injections  m  loco  dolenti.  If  the  case  resists  these 
methods  of  treatment,  excision  of  a  portion  of  the  nerve  may  be  per- 
formed. This  is  very  readily  done  in  the  case  of  the  occipitalis  major 
nerve,  on  account  of  its  superficial  position  during  the  greater  part  of  its 
course.  Very  few  cases,  however,  will  be  found  in  which  it  becomes  ne- 
cessary to  resort  to  such  extreme  measures.  In  fact,  in  my  experience, 
this  is  the  most  readily  curable  of  all  forms  of  neuralgia. 


CHAPTER  YIIl. 

BRACHIAL  NEURALGIA. 
Clinical  History. 

Although  one  of  the  more  infrequent  forms  of  neuralgia,  especially 
in  civil  life,  this  variety  often  rivals  trigeminal  neuralgia  in  intensity,  and 
is  also  interesting  on  account  of  the  numerous  and  important  trophic 
changes  with  which  it  may  be  complicated.  The  neuralgia  may  be 
strictly  limited  to  the  course  of  one  nerve,  but,  in  the  majority  of  patients, 
several  branches  of  the  brachial  plexus  are  involved  at  the  same  time. 
This  is  due  to  the  fact  that  the  nerves  are  situated  in  such  close  apposi- 
tion in  the  neck  and  arm,  and  that  there  are  frequent  anastomoses  be- 
tween them.  Henle  ("  Anatomie  des  Menschen  ")  has  furnished  a  plate 
representing  the  cutaneous  distribution  of  the  individual  nerves  of  the 
plexus,  but,  for  the  reasons  just  mentioned,  this  is  of  very  little  service 
in  practice. 

The  pains  of  this  variety  of  neuralgia  do  not  so  often  present  the  peri- 
odicity which  is  frequently  observed  in  other  forms  of  neuralgia,  ^.  e.,  the 
paroxysms  appear  more  irregularly  and,  at  the  same  time,  more  often  than 
in  other  varieties.  A  striking  characteristic  of  brachial  neuralgia  is  the 
fact  that  the  pains  dart  both  up  and  down  the  nerves  in  the  majority  of 
cases,  instead  of  merely  toward  the  periphery,  as  they  usually  do  in  other 
forms. 

Weir  Mitchell,'  to  whose  valuable  observations  we  are  largely  in- 
debted, has  applied  the  term  "  caifsalgia  "  to  one  form  of  pain  (observed 
in  traumatic  neuralgias),  which  he  describes  in  the  following  terms:  "  Its 
favorite  site  is  the  foot  or  hand.  The  great  mass  of  sufferers  described 
this  pain  as  superficial,  but  others  said  it  was  also  in  the  joints,  and  deep 
in  the  palm.     If  it  lasted  long  it  was  finally  referred  to  the  skin  alone. 

"  Its  intensity  varies  from  the  most  trivial  burning  to  a  state  of  tor- 
ture, which  can  hardly  be  credited,  but  which  reacts  on  the  whole  economy, 
until  the  general  health  is  seriously  affected.  The  part  itself  is  not  alone 
subject  to  an  intense  burning  sensation,  but  becomes  exquisitely  hyperaes- 
thetic,  so  that  a  touch  or  a  rap  of  the  finger  increases  the  pain.  Expos- 
ure to  the  air  is  avoided  by  the  patient  with  a  care  which  seems  absurd, 
and  most  of  the  bad  cases  keep  the  hand  constantly  wet,  finding  relief  in 
the  moisture  rather  than  in  the  coolness  of  the  apj^lication.  Two  of  these 
sufferers  carried  a  bottle  of  water  and  a  sponge,  and  never  permitted  the 
part  to  become  dry  for  a  moment.  As  the  pain  increases  the  general 
sympathy  becomes  more  marked.  The  temper  changes  and  grows  irrita- 
ble, the  face  becomes  anxious,  and  has  a  look  of  weariness  and  suffering. 
The   sleep  is  restless,  and  the  constitutional  condition,  reacting  on  the 


*  Injuries  of  Nerves,  1873. 


NEURALGIA.  >  137 

wounded  limb,  exasperates  the  hyperaesthetic  state,  so  that  the  rattling  of 
a  newspaper,  a  breath  of  air,  the  step  of  another  across  the  ward,  the  vi- 
brations caused  by  a  military  band,  or  the  shock  of  the  feet  in  walking, 
gives  rise  to  increase  of  pain.  At  last  the  patient  grows  hysterical,  if  we 
may  use  tlie  only  term  which  describes  the  facts.  He  walks  carefully, 
carries  the  limb  with  the  sound  hand,  is  tremulous,  nervous,  and  has  all 

kinds  of  expedients  for  lessening  his  pain Motion  of  the  part 

WHS  unendurable  in  some  of  the  very  worst  cases;  but,  for  tlie  most  part, 
it  did  no  harm,  unless  so  excessive  as  to  flush  the  injured  region." 

The  internal  cutaneous,  ulnar,  and  radial  nerves  are  the  ones  which 
are  most  frequently  involved,  but  it  is  comparatively  rare  to  find  even 
these  nerves  affected  to  the  entire  exclusion  of  other  branches.  This  cir- 
cumstance is  very  readily  understood,  if  w^e  remember  that  Arloing  and 
Tripier  have  shown  that  numerous  recurrent  sensory  fibres,  pass  from 
the  trunk  of  one  nerve  to  that  of  another  at  various  heights  (most  nu- 
merous as  the  nerves  approach  the  periphery). 

Brachial  neuralgia  is  frequently  associated  with  other  varieties,  espe- 
cially with  occipital  and  trigeminal  neuralgias,  as  we  have  already  stated 
in  discussing  these  affections. 

Numerous /)«;ic<a  dolorosa  are  mentioned  by  various  authors,  but  we 
have  found  very  few  which  are  constant.  A  spinal  point  over  the  lower 
cervical  vertebrfe  is  present  in  almost  all  cases  which  attain  any  considera- 
ble degree  of  severity.  An  axillary  point  is  also  frequently  observed  over 
the  course  of  the  plexus  in  the  axillary  space.  At  the  elbow  we  may  find 
an  ulnar  point,  between  the  olecranon  process  and  the  internal  condyle; 
an  external  cutaneous  point,  above  the  external  condyle,  where  the  mus- 
culo-cutaneous  nerve  becomes  superficial.  The  other  painful  points  are 
inconstant. 

The  motor  complications  are  not  very  important;  they  consist  of  stiff- 
ness of  the  limb  from  rigidity  of  the  muscles,  and  this  may  even  be  so  se- 
vere as  to  lead  to  considerable  contracture.  Muscular  atrophy  may  de- 
velop, both  from  disuse  of  the  limb  and  from  an  affection  of  the  trophic 
fibres  in  the  course  of  the  nerves.  Fibrillary  twitching-s  of  the  muscles 
are  sometimes  observed,  and  even  tonic  and  clonic  convulsions  of  the  en- 
tire limb  have  been  noticed.  These  phenomena  are  not,  however,  by  any 
means  so  frequent  as  in  neuralgic  affections  of  the  lower  limb,  except  in 
cases  in  which  the  disease  is  due  to  a  direct  wound  of  the  nerve. 

Hyperresthesia,  or  more  properly  speaking-,  hyperalgesia  of  the  skin,  is 
a  frequent  complication.  The  integument  may  be  exquisitely  painful  to 
the  slightest  touch,  while  tactile  sensibility  is  unaltered  or  diminished. 
The  patients  also  often  complain  of  a  sensation  of  formication  and  numb- 
ness. 

The  trophic  complications  are  at  once  the  most  interesting  and 
important,  but  they  do  not  attain  any  considerable  intensity  unless  the 
neuralgia  is  due  to  an  injury  of  the  nerve.  The  skin  and  its  appendages 
are  the  parts  most  frequently  involved,  giving  rise  to  what  is  known  as 
glossy  skin.  This  condition,  as  far  as  w^e  know,  is  limited  to  the  fingers 
and  to  the  palm  or  dorsal  surface  of  the  hand.  The  integument  of  the 
affected  portion  appears  to  be  thinner  than  normal,  the  creases  are  par- 
tially or  entirely  effaced,  as  if  the  skin  were  drawn  tightly  over  the  bones, 
and  it  has  a  peculiar  shining  look.  Glossy  skin  is  usually  combined  with 
hypertesthesia  of  the  integument,  though  we  have  not  seen  it  attended 
with  the  burning  pain  which  Weir  Mitchell  mentions  (none  of  my  cases, 
however,  were  of   a  severe  character).     Various  eruptions   have  been  ob- 


138  FUNCTIONAL    NERVOUS   DISEASES. 

served  upon  the  skin,  such  as  herpes  (which  runs  along  the  course  of  one 
of  the  superficial  nerves),  ordinary  eczema,  pemphigus,  etc.  Foul-look- 
ing and  very  obstinate  ulcers  may  be  left  in  the  wake  of  these  eruptions. 
Diminution  of  perspiration  is  the  only  secretory  disorder  of  the  skin  which 
1  have  noticed,  but  Weir  Mitchell  has  observed,  in  addition,  excessive  se- 
cretion of  sweat,  which  was  sometimes  of  "  a  disagreeable  odor,  like  vine- 
gar." The  hair  presents  the  same  modifications  which  we  have  refei-red 
to  in  connection  with  trigeminal  neui-algias,  viz.,  atrophy,  hypertrophy, 
change  of  color,  and  brittleness.  The  nails  may  also  suffer,  the  rate  of 
growth  is  diminished,  they  become  more  strongly  curved  in  both  direc- 
tions, fissures  appear  in  them,  and  they  present  a  dirty,  yellowish  color. 

Finally,  we  must  refer  to  a  peculiar  affection  of  the  joints,  which  may 
involve  any  of  the  articulations  of  the  limb,  but  is  usually  confined  to  the 
fingers.  In  one  case  under  my  observation  all  the  joints  of  the  fingers  of 
the  left  hand,  together  with  the  elbow-joint,  were  involved.  The  ends  of 
the  bones  appear  to  be  swollen,  slight  redness  and  perhaps  a  little  swell- 
ing is  sometimes  observed  around  the  joints,  and  they  are  extremely  ten- 
der upon  the  slightest  pressure  in  any  direction.  Contracture  and  anky- 
losis of  the  affected  joints  are  very  apt  to  develop  under  these  circum- 
stances. The  following  case,  reported  by  Weir  Mitchell,  is  a  good  illus- 
tration of  the  manner  in  which  these  changes  may  be  combined. 

Case  III. — B.  D.  L.,  aged  forty-three,  a  farmer  from  Maine.  Enlisted, 
July,  1862.  He  was  healthy  to  the  date  of  his  wound,  received  July  2, 
18G3x  at  Gettysburg.  While  kneeling  and  aiming,  he  was  shot  in  the  right 
side  of  the  neck.  He  felt  pain  in  the  wound,  but  none  down  the  arm.  He 
spun  around,  feeling  stunned,  and  fell  on  his  back,  not  unconscious.  In 
five  minutes  he  arose  and  walked  to  the  rear,  where  the  wound  was  dressed 
with  cold  water,  no  splint  being  employed  either  then  or  later.  .  At  first 
all  motion  was  lost.  In  an  hour  he  could  move  his  fingers  and  abduct 
the  arm,  but  not  flex  it.  He  thinks  sensation  Avas  perfect,  except  as  to 
the  ulnar  distribution.  Within  an  hour  he  had  severe  earache,  and  pain 
in  the  shoulder,  arm,  and  forearm.  During  the  second  week  he  began  to 
have  burning  pain  in  the  hand.  At  this  time,  which  probably  marked 
the  onset  of  neuritis,  the  shoulder-joint  grew  stiff,  then  the  elbow,  and 
lastly  all  of  the  fingers.  This  condition  was  excessively  painful,  and  re- 
mained unchanged.  The  tremor,  which  is  constant  in  the  upper  arm  mus- 
cles, began  the  day  of  the  wound,  and  had  not  ceased  on  his  admission  to 
our  wards. 

Site  of  vjound.— On  admission,  October,  18G3,  it  was  noted  that  the 
ball  had  entered  the  right  side  of  the  neck,  in  front,  three  inches  above 
the  clavicle,  in  the  outer  edge  of  the  trapezius.  The  missile  passed  down- 
ward and  outward,  and  struck  the  anterior  edge  of  the  supra-spinal  fossa 
of  the  scapula,  five  inches  external  to  the  spine  of  the  first  dorsal  vertebra. 
Both  wounds  sloughed,  leaving  scars  one  and  a  half  inches  in  diameter. 
The  patient  is  well  and  florid.  The  shoulder  is  motionless  from  stiffness. 
The  lower  joints  are  alike  stiff,  swollen,  red,  and  painful  ;  the  arm,  semi- 
prone  and  flexed,  is  carried  across  the  chest,  supported  by  the  sound  hand. 
He  has  slight  motion  throughout,  but  the  effort  causes  fibrillar  tremor 
and  exquisite  pain. 

Sensation. — The  sense  of  touch  is  everywhere  good,  save  that  there  is 
slight  numbness  of  the  back  of  the  hand  and  forearm.  Some  causalgia  is 
felt  in  the  palm,  but  no  other  pain,  except  on  movement. 

Nutrition. — The  palm  is  thin  and  red  and  purplish,  and  on  it  the  pa- 


NEITRALGIA.  139 

tient  uses  water,  now  and  then,  as  a  dressing;  there  is  no  atrophy;  the 
wound  is  healed,  but  tender,  as  are  also  the  upper  nerve-tracks.  Muscu- 
lar hypera?sthesia  of  the  deltoid  and  tricej^s  is  present.  The  nails  are 
remarkably  curved,  the  hair  is  scanty,  the  sweat  ill-smelling  and  acid. 
The  shoulder  muscles  alone  have  lost  electro-muscular  contractility  (in- 
duction current).  Under  ether,  the  joints  when  moved  are  found  to  be 
free  from  well-marked  organic  adhesions. 

Passive  motion  and  electricity  caused  speedy  pain  in  movement,  and 
in  February,  1864,  he  was  able  to  move  all  the  joints  with  diminished 
pain.  The  muscles  were,  at  this  time,  sensitive  to  induced  currents,  and 
the  numbness  and  causalgia  had  nearly  disappeared.  He  was  allowed  a 
furlough,  at  the  expiration  of  which  he  deserted. 


Etiology. 

Brachial  neuralo^ia  resembles  sciatica  with  regard  to  etiology,  in  the 
fact  that  both  are  frequently  caused  by  agencies  which  act  upon  the  nerves 
after  their  escape  from  the  spinal  canal.  Heredity  plays  a  very  unim- 
portant part  in  its  causation,  and  Anstie  only  mentions  one  case  in  which 
the  patient's  family  presented  a  neuropathic  history.  It  is  so  rarely  due 
to  this  cause  that  the  majority  of  authors  do  not  refer  to  it.  Salter  re- 
ports several  cases  of  this  form  of  the  disease  which  were  due  to  the  reflex 
irritation  of  a  carious  tooth,  and  other  observers  have  reported  similar 
cases.  Salter  believes  that  such  patients  suffer  from  a  predisposition 
(either  acquired  or  congenital)  to  neuralgia.  Not  an  inconsiderable  num- 
ber of  cases  occur  as  complications  of  occipital  and  sometimes  of  trigem- 
inal neuralgia.  The  brachial  neuralgia  then  presents  a  lesser  severity, 
but  I  have  sometimes  noticed  that  this  form  persists  after  the  occipital 
or  trigeminal  affections  have  disappeared.  Constitutional  diseases,  such 
as  malaria  and  syphilis,  are  very  rai'ely,  if  ever,  the  causes  of  this  form  of 
the  disease.  The  large  majority  of  the  cases  are  due  to  local  causes,  which 
may  be  situated  at  the  spinal  column,  in  the  course  of  the  nerves,  or  at 
their  peripheral  distril^ution.  The  lesions  of  the  vertebrse  which  may 
give  rise  to  it  include  spondylitis  deformans,  caries,  and  carcinoma.  Braun 
reports  seven  cases  in  which  this  was  one  of  the  symptoms  of  spondylitis 
deformans  affecting  the  cervical  vertebrce.  This  is  readily  determined  by 
the  local  tenderness  on  pressure  and  by  the  presence  of  deformity,  espe- 
cially of  the  lateral  masses.  We  refer  to  pages  144,  145  for  our  remarks 
on  the  diagnosis  of  caries  and  carcinoma  of  the  vertebrae. 

Brachial  neuralgia  may,  for  a  considerable  period,  be  the  sole  symp- 
tom of  chronic  cervical  pachymeningitis;  as  a  rule,  the  affection  is  then 
bilateral  and  is  combined  with  double  occipital  neuralgia.  It  may  be  im- 
possible to  determine  the  origin  of  the  neuralgia  for  a  month  or  two,  but 
other  characteristic  symptoms  of  pachymeningitis  then  make  their  appear- 
ance, consisting  of  gradually  increasing  motor  paralysis  of  the  arms,  with 
contracture  and  progressive  muscular  atrophy,  especially  involving  the 
hands. 

As  I  have  remarked  in  the  chapter  on  the  etiology  of  occipital  neu- 
ralgia (page  133),  I  have  long  thought  that  this  form,  as  well  as  brachial 
neuralgia,  may  be  sometimes  due  to  subacute  meningitis  of  the  cervical 
portion  of  the  cord.  ' 

In  the  course  of  the  nerves  numerous  exciting  causes  have  been  noted, 
such  as  aneurism  of  the  subclavian  artery,  pressure  from  adjacent  tumors. 


140  FUNCTIONAL    NERVOUS    DISEASES. 

wounds  of  various  kinds  (gunshot,  lancet,  knife),  pressure  of  the  frac- 
tured end  of  a  bone  or  of  superabundant  callus,  implication  of  the  nerves 
in  a  retracting  cicatrix,  a  direct  blow,  etc. 

The  exciting  causes  at  the  peripheral  distribution  of  the  nerves  in- 
clude the  pressure  of  true  or  false  neuromata,  and  the  irritation  arising 
from  punctured  wounds.  Three  of  my  cases  were  due  respectively  to  the 
thrust  of  a  rusty  needle,  a  nail,  and  the  point  of  a  pair  of  scissors  into  the 
fingers.  In  all  of  these  cases  the  neuralgia  affected  various  nerve-branches 
in  the  forearm  and  shoulder. 


Diagnosis  and  Prognosis. 

Brachial  neuralgia  is  sometimes  mistaken  for  myalgia  of  the  shoulders 
and  arms,  but  the  previous  remarks  which  we  have  made  on  this  subject 
will  also  apply  here.  Rheumatic  inflammation  of  the  shoulder-  or  elbow- 
joints  is  recognized  by  the  existence  of  fever,  swelling  of  the  affected 
joints,  local  heat  and  tenderness,  and  the  evident  implication  of  the  gen- 
eral sj^stem.  There  is  very  little  danger,  however,  of  making  such  mis- 
takes unless  the  case  is  examined  superficially,  and  too  much  reliance 
placed  upon  the  patient's  statement  that  he  is  suffering  from  "  neuralgia," 
a  term  which,  in  the  mouths  of  the  laity,  is  expressive  of  very  many  con- 
ditions. 

The  main  diflficulty  consists  in  a  determination  of  the  exciting  cause 
of  the  disease.  Whenever  the  affection  is  bilateral,  and  especially  when 
it  is  combined  with  occipital  neuralgia,  we  must  pay  special  attention  to 
the  condition  of  the  spinal  column,  and  consider  the  possibility  of  the  dis- 
ease being  secondary  to  spond3'litis  deformans,  caries,  or  carcinoma  of  the 
vertebrge.  We  shall  enter  into  this  subject  m.ore  in  detail  under  the  head- 
ing o£  intercostal  neuralgia,  and  refer  the  reader  to  page  144  for  our  re- 
marks on  the  subject.  Chronic  cervical  pachymeningitis  is  recognized  by 
its  steady  progress,  the  implication  of  the  occipital  nerves  as  well  as  the 
brachial  plexuses,  the  coietinually  progressing  paralysis  and  atrophy  of  the 
muscles  of  the  upjier  limbs,  especially  the  hands,  the  development  of  con- 
tracture of  the  upper  limbs,  and  the  final  spread  of  the  motor  and  sensoiy 
disturbances  to  the  lower  limbs. 

Those  agencies  which  we  have  enumerated  in  the  section  on  etiology 
as  acting  upon  the  nerves  after  their  exit  from  the  vertebral  canal,  must 
be  determined  by  an  accurate  history  of  the  case,  and  a  careful  examin- 
ation of  the  arm  by  sight  and  touch.  In  obscure  cases  we  must  carefully 
examine  the  chest  in  order  to  determine  whether  the  neuralgia  may  not 
be  due  to  the  pressure  of  a  subclavian  aneurism,  or  other  intra-thoracic 
growth. 

Treatment. 

One  of  the  essential  features  in  the  treatment  of  brachial  neuralgia, 
whatever  maybe  its  origin,  is  the  maintenance  of  entire  rest  of  the  parts. 
We  not  infrequently  find  that,  after  the  disease  has  been  apparently  cured, 
a  relapse  readily  occurs  in  consequence  of  some  unusual  exercise. 

During  a  paroxysm  of  pain  the  instincts  of  the  patient  will  teach  him 
to  hold  the  arm  quiet,  but  he  must  also  be  enjoined  to  shun  manual  exer- 
cise for  several  weeks  after  the  pain  has  disappeared. 

Medicinal  measures  are  of  little  avail  in  this  affection.   When  the  par- 


NEURALGIA.  141 

oxysms  are  unendurable  we  must,  of  course,  resort  to  the  use  of  hypodor- 
mic  injections  of  morphine  or  some  of  its  substitutes. 

Galvanism  has  proven  by  far  the  best  remedial  agent,  in  my  hands, 
in  the  treatment  of  this  aifection.  One  electrode  (it  is  immaterial  which) 
should  be  applied  over  the  lower  cervical  vertebra?,  and  the  other  over  the 
course  of  the  brachial  plexus  in  the  arm  (the  current  should  be  moderately 
strong  and  not  applied  longer  than  five  to  ten  minutes).  If  the  neuralgia 
affects  only  the  nerves  in  the  arm,  this  application  will  be  sufficient;  but  if 
the  forearm  is  also  involved,  a  second  application  should  be  made,  one 
electrode  being  now  applied  to  the  plexus  and  the  other  to  the  affected 
nerve.     The  sittings  may  be  held  daily,  or  every  other  day. 

Counter-irritation  is  usually  a  valuable  adjuvant,  especially  when  the 
disease  is  due  to  spondylitis  deformans.  In  the  latter  event,  the  counter- 
irritation  is  best  secured  by  the  application  of  tincture  of  iodine,  repeated 
with  sufficient  frequency  to  cause  blistering;  warm  baths  are  also  very 
serviceable  in  these  cases.  In  those  cases  which  are  not  due  to  spondy- 
litis, we  may  employ  emplastrum  cantharidis  over  the  vertebra?,  and,  in 
obstinate  cases,  over  the  tender  spots  in  the. course  of  the  nerves.  The 
actual  cautery  may  also  be  resorted  to,  especially  along  the  nerve-trunks. 
This  measure  sometimes  produces  admirable  results  within  a  very  short 
period. 

Surgical  interference  is  frequently  required  in  this  form  of  neuralgia, 
either  to  relieve  the  nerves  from  the  pressure  of  a  strangulating  cicatrix 
or  of  superabundant  callus,  to  remove  a  neuroma,  etc.  I  noticed  as  a 
curious  fact  in  the  three  cases  previously  mentioned  as  due  to  the  prick  of 
a  pin,  blade  of  scissors,  and  nail,  and  in  which  the  neuralgia  appeared  in 
almost  all  the  nerves  of  the  arm,  that  the  pain  was  very  markedly  im- 
proved after  several  applications  of  the  faradic  current  to  the  finger  which 
had  been  the  site  of  the  injury.  In  some  inveterate  cases  it  will  become 
necessary  to  resort  to  section  or  resection  of  the  nerves;  in  such  cases 
great  caution  must  be  exercised,  and  the  patient  very  carefully  examined 
in  order  to  determine  which  nerve  or  nerves  should  be  operated  upon. 
This  problem  is  often  solved  with  great  difficulty  on  account  of  the  abun- 
dance of  recurrent  sensory  fibres.  Some  successful  cases  of  nerve-stretch- 
ing for  brachial  neuralgia  have  been  reported,  and  in  these,  as  in  all  other 
mixed  nerves,  it  is  not  at  all  improbable  that  this  operation  will  finally 
supersede  that  of  neurectomy  entirely. 

In  the  terrible  form  of  neuralgia  known  as  causalgia,  Weir  Mitchell 
recommends  the  continual  application  of  water  dressings  to  the  affected 
part,  and  repeated  blisters;  hypodermic  injections  of  morphine,  preferably 
into  the  seat  of  pain,  are  indicated  when  the  pain  is  intolerable. 


CHAPTER  IX. 

INTERCOSTAL   NEURALGIA. 
CLi>ficAL  History. 

This  constitutes  one  of  the  most  frequent  as  well  as  the  mildest  forms 
of  neuralgia.  The  pain  is  strictly  confined  to  the  course  of  the  nerves 
(in  the  vast  majority  of  cases  to  the  anterior  branches),  and  the  parox- 
ysms differ  in  no  respect  fvom  those  of  other  varieties  of  this  affection. 
If  the  pain  is  severe  the  patient  leans  toward  the  affected  side  (usually 
the  left),  and  is  afraid  to  take  a  long  breath.  A  paroxj^sm  may  be  ex- 
cited by  coughing,  sneezing,  or  any  other  sudden  movement  in  which  the 
thorax  and  abdomen  take  part.  The  pain  is  usually  felt  on  the  left  side, 
from  the  sixth  to  ninth  intercostal  spaces.  In  one  variety  of  intercostal 
neuralgia,  which  sometimes  attains  an  intolerable  intensity,  the  breast  is 
the  seat  of  pain,  usually  in  the  female,  though  a  few  cases  have  been  re- 
ported in  the  male  (Cooper's  irritable  breast).  This  pain  is  purely  neural- 
gic in  character,  and  does  not  appear  to  follow  the  definite  course  of  any 
single  nerve,  but  darts  through  the  breast  in  all  directions.  In  neuralgia 
of  the  breast,  as  well  as  in  ordinary  intercostal  neuralgia,  the  integument 
is  often  extremely  hyperjesthetic  (in  the  former  case  over  the  entire 
breast,  and  in  the  latter  along  the  course  of  the  painful  nerve),  so  that 
the  slightest  touch  is  unendurable;  the  patients  frequently  complain  of 
the  pain  caused  by  the  pressure  of  the  clothes.  In  many  cases,  however, 
firm  pressure  over  the  painful  region  will  produce  decided  relief.  After 
a  certain  length  of  time  the  h^^perfesthesia  gives  way  to  anaesthesia, 
though  I  have  often  observed  the  former  condition  even  aftor  the  disease 
has  lasted  for  a  long  period. 

Puncta  dolorosa  are  very  generally  observed  in  this  disease,  though 
it  would  be  a  mistake  to  believe  that  they  constitute 'an  absolutely  essen- 
tial feature.  They  are  usually  three  in  number,  but  one  or  even  two  of 
these  may  be  absent.  They  are  termed  respectively  the  spinal  point, 
which  is  situated  to  one  side  of  the  spinous  process  at  the  exit  of  the 
nerve  from  the  intervertebral  foramen,  the  axillary,  situated  near  a  line 
dropped  from  the  middle  of  the  axillary  space,  and  the  sternal  point, 
about  an  inch  from  the  sternum,  or,  in  the  nerves  distributed  to  the  abdo- 
men, near  the  median  line  over  the  rectus  muscle. 

Herpes  zoster  is  the  onlj''  complication  of  intercostal  neuralgia  which 
possesses  any  importance.  From  the  frequency  with  which  herpes  is  re- 
ferred to  as  a  complication  of  neuralgia  in  foreign  journals,  it  appears  to 
be  much  more  common  in  Europe  than  it  is  in  our  own  country.  Accord- 
ing to  Baerensprung  it  is  more  frequent  on  the  right  side  than  on  the  left; 
in  very  rare  instances  it  is  bilateral,  and  encircles  the  trunk  like  a  girdle. 
Its  appearances  are  similar  to  those  observed  in  ophthalmic  zoster,  and 
we  refer  the  reader  to  tJie  description  of  the  former  affection  on  page  95. 


ISTEURALGIA.  143 

Sometimes  the  eruption  appears  prior  to  the  development  of  the  neural- 
gia, at  other  times  the  latter  ceases  as  soon  as  tlie  herpes  has  devel- 
oped. It  is  frequently  a  very  obstinate  and  distressing  coniplicatioii,  and 
the  slightest  contact  with  the  ulcerated  surface  may  cause  excruciating 
agony. 

Intercostal  neuralgia  differs  somewhat  from  other  varieties  in  the  fact 
that  the  patients  often  suffer  from  a  dull,  steady  pain  along  the  nerve 
during  the  intervals  between  the  paroxysms,  and  this  interparoxysmal 
pain  is  often  a  source  of  considerable  distress;  it  is  sometimes  so  severe 
that  the  patients  are  compelled  to  restrain  the  movements  of  respiration 
on  one  side,  as  in  cases  of  pleurisy  with  effusion. 

This  disease  is  frequently  combined  with  trigeminal  and  other  neural- 
gias, but  it  always  follows  in  the  wake  of  the  latter,  and  does  not  attain 
an  equal  severity.  Anstie  mentions  a  case  of  death  from  intercostal  neu- 
ralgia in  a  woman  set.  70  years,  in  whom  the  disease  was  complicated  with 
intractable  herpes  ;  death  was  directly  due  to  exhaustion,  consequent  on 
the  severe  and  protracted  pain.  This  case,  however,  is  an  extremely  ex- 
ceptional one,  and  I  can  find  no  reports  of  similar  ones. 


Etiology. 

m 

The  large  majority  of  cases  of  intercostal  neuralgia  develop  in  women 
between  the  ages  of  twenty  and  forty  years.  It  is,  however,  not  infre- 
quently met  with  in  girls  at  the  agie  of  puberty,  and  sometimes  also  plays 
a  part  in  the  affection  which  we  have  termed  the  menopause  neurosis 
(page  100). 

The  period  in  which  intercostal  neui-algia  usually  appears  corresponds 
to  the  child-bearing  age,  and  this  is  explained  by  the  fact  that  itpommon- 
ly  results  from  excessive  lactation,  profuse  leucorrhoea,  and,  as  we  have 
observed  in  many  cases,  after  the  patient  has  lost  considerable  blood  dur- 
ing deliver3\  These  patients  always  present  evidences  of  anaemia,  such 
as  palpitation  of  the  heart,  shortness  of  breath  on  slight  exercise,  drow- 
siness in  the  day-time,  and  often  insomnia  at  night,  weakness,  anremic 
heart-murmurs,  etc.  We  desire  to  call  attention  to  the  fact  that  this 
class  of  patients,  although  markedly  ani^mic,  often  present  a  very  ruddy 
complexion,  which  is  sometimes  so  marked  that  we  have  seen  physicians 
make  a  diagnosis  of  congestion  of  the  brain  from  the  mere  appearance  of 
the  face.  Upon  close  inquiry  it  will  be  found,  however,  that  the  redness 
often  allernates  with  sudden  pallor,  and  this  symptom  is  probably  due  to 
vaso-motor  paralysis  as  the  result  of  the  profound  ani'emia. 

Malaria  is  very  rarely  a  cause  of  intercostal  neuralgia,  and  periodicity 
is  not  well  marked  in  this  variety. 

Exposure  to  cold,  etc.,  also  plays  a  very  unimportant  part  in  the  eti- 
ology of  the  affection,  and  changes  in  temperature  possess  very  little  in- 
fluence on  the  intensity  of  the  jiain. 

The  other  causes  of  intercostal  neuralgia  are  also  infrequent,  and 
chiefly  include  various  affections  of  the  vertebrae  or  membranes  of  the 
spinal  cord.  It  is  not  uncommonly  one  of  the  first  symptoms  of  Pott's 
disease,  and  is  very  generally  present  in  the  later  stages  when  an  aliscess 
has  formed  which  presses  upon  the  cord  or  upon  the  roots  of  the  nerves. 
It  is  also  a  frequent  symptom  of  locomotor  ataxia.  But  we  must  not 
confound  the  cincture  feeling-  of  ataxia  with  true  neuralgia,  as  the  former 
lacks  the  essential   features  of  neuralgic  pain.     Intercostal  neuralgia  is 


144  FUNCTIONAL    NERVOUS    DISEASES. 

also  a  symptom  of  spondylitis  deformans  and  of  carcinoma  of  the  vertebrae. 
In  tlie  latter  affection  it  is  always  bilateral,  and,  as  in  the  case  which  we 
mentioned  on  page  114,  the  pains  may  present  such  perfect  periodicity  as- 
to  lead  to  a  diagnosis  of  malarial  infection.  The  neuralgia  of  carcino- 
m:i3  vertebrariuu  is  usually  caused  by  pressure  upon  the  nerves  at  their 
exit  from  the  intervertebral  foramina.  Finally,  aortic  aneurism  (of  the 
descending  arch  or  abdominal  portion)  sometimes  gives  rise  to  intense  in- 
tercostal neuralgia,  usually  on  one  side.  In  one  obstinate  case  under  my 
cliarge,  a  neuralgia  of  the  ninth  intercostal  nerve  was  apparently  due 
to  the  pressure  of  a  lipomatous  tumor  upon  the  nerve  in  the  first  half  of 
its  course.  In  rare  instances  caries  or  necrosis  of  the  ribs  may  also  give 
rise  to  this  disease. 

As  this  is  usually  a  mild  form  of  neuralgia,  we  should  always  examine- 
the  patient  carefully  for  the  organic  diseases  we  have  mentioned  above* 
whenever  the  pain  does  not  yield  readily  to  treatment. 


Diagnosis. 

Intercostal  neuralgia  is  frequently  mistaken  for  pleurodynia  or  muscu- 
lar rheumatism  involving  the  muscles  which  cover  the  ihorax.  It  resem- 
bles this  affection  in  the  fact  that  the  latter  is  also  increasec^  by  move- 
ments of  respiration,  and  that  the  breathing  is  therefore  shallow  on  the' 
affected  side.  But  the  pain  does  not  follow  the  course  of  any  definite 
nerve,  and  is  never  shooting  in  character;  furthermore,  the  puncta  dolo- 
rosa and  hyperjesthesia  of  the  integument  are  wanting.  These  patients 
are  also  very  liable  to  suffer  from  muscular  rheumatism  in  other  localities, 
especially  the  shoulders  or  back  of  the  neck. 

Pleurisy,  in  which  the  pain  is  often  of    a  neuralgic  character,  is  dis- 
tinguished by  the  clinical  history  as  well  as  by  the  results  of  physical  ex- 
amination (friction  murmur,  dulness  or  flatness  on  percussion,  which  varies 
with  the  change  in  the  position  of  the  patient,  diminished  vocal  resonance, 
etc.).     Before  the  exudation  has  been  formed,  however,  it  is  often  very 
difficult  to  differentiate  the  two  affections,  and  sometimes  the  dOubt  is  only 
cleared  up  by  the  subsequent  history  of  the  case.     It  is  not  sufficient  to 
have  made  a  diagnosis  of  intercostal  neuralgia;  we  should  also  endeavor 
to  determine  its  origin,  and  especially  whether  it  is  symptomatic  of  any 
more  serious  affection.     It  is    sometimes   one  of  the  first   symptoms  of 
Pott's  disease,  and  it  may  be  very  difficult,  in  the  beginning,  to  determine 
the  nature  of  the  primary  affection.     As  we  have  stated  in  the  remarks 
on  its  etiology,  intercostal  neuralgia  is  most  frequent  between  the  ages 
of  twenty  and  forty  years,  and  its  development  in  a  young  child  should 
therefore  put  us  on  our  guard.     In  addition  to  the  youthful  age  of  the 
patient,  inquiry  should  be  made  with  regard  to  previous  strumous  history, 
and  to  injury  to  the  spine  from  a  fall  or  blow.     An  additional  differential 
point  of  importance  is  the  usually  bilateral  character  of  the  neuralgia  in 
Pott's  disease,  whereas  the  idiopathic  variety  is  almost  invariably  unilat- 
eral.    In  Pott's  disease  the  affected  vertebra  are  tender  on  pressure  with 
tlie  finger,  and  pain  is  also  produced  when  the  patient  comes  down  firmly 
upon  his  heels.     In  addition,  the  patients  grow  tired  after  slight  exertion, 
and  the  movements  of  the  affected  portion  of   the  spinal  column  are  stiff 
and  slower  than  usual.     The  manner  in  which  the  patients  sit  down  or 
rise  from  a  chair  is  very  characteristic.     They  move  slowly,  assist  them- 
selves in  rising  by  grasping  the  arms  of  the  chair,  and  keep  the  spinal  col- 


NEURALGIA.  145 

umn  stiff.  At  a  later  stag-e  of  tlie  disease,  deformity  of  the  vertebral  col- 
umn becomes  manifest.  Although  this  is  a  very  valuable  sign  of  Pott's 
disease,  it  must  be  remembered  that  it  is  not  absolutely  pathognomonic  in 
all  cases,  and  that  other  symptoms  must  be  present  in  order  to  justify  such 
a  diagnosis. 

When  the  intercostal  neuralgia  is  secondary  to  spondylitis  deformans, 
this  affection  is  readily  determined  by  visual  and  tactile  exploration, 
which  reveals  the  presence  of  an  irregular  deformity,  usually  situated 
over  one  lateral  mass;  it  sometimes  converts  the  entire  vertebra  into  an 
irregular,  misshapen  mass,  and  may  cause  ankylosis  between  it  and  the 
adjacent  vertebrae.  It  is  a  disease  of  adult,  and  usually,  in  fact,  of  ad- 
vanced life,  and  this  circumstance  furnishes  one  of  the  most  important 
differential  points  between  it  and  Pott's  disease. 

Intercostal  neuralgia,  like  other  forms  of  this  affection,  may  also  be 
secondary  to  carcinoma  of  the  vertebrre.  It  is  sometimes  extremely  diffi- 
cult to  diagnose  the  primary  affection.  The  latter  disease  usually  de- 
velops in  females  after  the  age  of  forty,  and  is  generally  secondary  to 
carcinoma  in  other  parts  of  the  body.  The  local  symptoms  are  very  obscure, 
and  do  not  aid  much  in  the  diagnosis.  In  three  very  well  marked  cases 
which  have  come  under  my  observation,  not  the  slightest  deformity  of  the 
spine  was  discoverable.  A  characteristic  feature  of  this  affection  is  the 
terrible  intensity  of  the  neuralgic  pains,  and  the  fact  that  treatment  has 
no  effect  upon  them.  We  are  compelled  to  resort  to  continually  increas- 
ing doses  of  morphine,  until  finally  enormous  doses  must  be  taken  in 
order  to  produce  even  moderate  palliative  effects. 

All  of  my  cases  were  secondary  to  carcinoma  of  the  breast,  and  the 
discovery  of  cancer  in  any  of  the  organs  of  the  body  is  one  of  the  most 
important  aids  in  diagnosis. 

Tkeatmekt. 

A  considerable  proportion  of  the  cases  develop  in  young  married 
women,  suffering  from  profuse  leucorrhoea,  who  are  in  the  habit  of  nurs- 
ing their  children  for  an  excessively  long  period  (sometimes  even  two 
years  in  the  hope  of  preventing  impregnation).  The  indications  there- 
fore are  to  relieve  the  anaemia  produced  by  these  drains  on  the  vital 
powers.  The  child  should  be  taken  from  the  breast  as  soon  as  prac- 
ticable, and  fed  from  the  bottle.  This  is  usually  in  the  interest,  not 
only  of  the  mother  but  also  of  the  child,  since  the  breast-milk  is  apt 
to  be  poor  in  quality  under  such  conditions.  The  leucorrhoea  is  merely 
the  result  of  the  low  condition  of  the  system,  and  may  usually  be  relieved 
within  a  very  short  time  by  prolonged  vaginal  injections  of  hot  water 
(morning  and  evening  for  ten  to  fifteen  minutes  at  a  time).  A  mild 
stimulant  (beer  or  porter)  may  be  taken  with  the  meals,  and  a  ferrugi- 
nous tonic  administered  (dialyzed  iron  or  the  formula  of  the  tincture  of 
the  chloride  which  we  have  so  often  recommended).  These  cases  improve 
in  a  few  days  under  such  treatment,  and  are  generally  entirely  relieved 
within  a  couple  of  weeks. 

Cases  due  to  other  causes  are  usually  of  a  more  severe  character,  and 
may  require  more  active  measures  of  treatment.  Here  also  we  must 
look  for  sources  of  debility  and  anremia,  and  endeavor  to  remove  them 
if  possible.  In  the  w^ay  of  medication,  we  may  supplement  the  use  of 
iron  by  the  addition  of  round  doses  of  quinine.  Even  those  cases  which 
are  not  of  a  malarial  nature  (comparatively  few  are)  derive  great  benefit 
10 


146  FUNCTIONAL   NERVOUS   DISEASES. 

from  doses  which  will  produce  a  slight  grade  of  cinchonism  for  two  or 
three  days. 

Counter-irritation  also  proves  very  useful;  we  have  derived  most 
benefit  from  the  application  of  blisters  over  the  spinal  painful  point,  ac- 
cording to  Anstie's  recommendation.  If  this  plan  does  not  succeed,  we 
may  apply  them  in  succession  over  the  various  puncta  dolorosa.  The 
blisters  need  not  exceed  an  inch  to  an  inch  and  a  half  in  size,  and  as  soon 
as  one  spot  heals  another  one  may  be  applied.  The  electrical  wire  brush 
over  the  spinal  painful  point  has  also  been  used  as  a  means  of  counter- 
irritation  with  some  success.  In  severe  cases  the  use  of  hypodermic  in- 
jections of  morphine  or  atropine,  and  the  constant  galvanic  current 
become  necessary.  The  latter  agent  does  not  by  any  means  possess  the 
same  efficacy  in  this  form  of  neuralgia  as  it  does  in  some  others,  notably 
sciatica.  In  one  obstinate  case  surgical  interference  was  resorted  to  by 
Nussbaum,  who  excised  a  portion  of  one  of  the  intercostal  nerves  in  order 
to  obtain  relief  from  the  excruciating  pain.  The  operation  was  entirely 
successful,  although  the  disease  had  existed  for  twenty  years  prior  to  the 
operation. 

"When  intercostal  neuralgia  is  complicated  with  herpes  zoster,  very 
little  can  be  done  for  the  eruption  itself.  It  should  be  merely  coated 
with  a  mild  dusting  powder,  such  as  subnitrate  of  bismuth  or  powdered 
starch,  to  prevent  the  contact  of  the  air,  and  care  should  be  taken  to  keep 
the  clothes  from  rubbing  against  the  ulcers.  The  galvanic  current  (one 
electrode  upon  the  spinal  column  at  the  exit  of  the  affected  nerve,  the 
other  along  its  course)  often  gives  excellent  results  in  such  cases,  though 
in  others  it  does  not  produce  the  slightest  beneficial  effect. 


CHAPTER  X. 

LUMBAR  NEURALGIA.' 
Clinical  History. 

WiiEX  compared  with  sciatica  or  trigeminal  neuralgia,  this  form  is 
relatively  infrequent,  especially  in  the  male  sex,  though  it  is  not  so  rare 
as  generally  believed.  Its  apparent  rarity  is  due  to  a  widespread  ten- 
dency to  classify  all  neuralgic  affections  of  the  lower  limbs  under  the  gen- 
eric head  of  sciatica.  All  branches  of  the  lumbar  plexus  are  never  in- 
volved at  one  time,  the  affection  being  generally  limited  to  one  or  two 
trunks.  In  the  majority  of  cases  the  pain  does  not  attain  any  great  se- 
verity, but  at  times  the  paroxysms  rival  those  of  tic  douloureux  in 
intensity. 

The  most  generally  affected  nerve  in  lumbar  neuralgia  is  one  of  the 
cutaneous  branches  of  the  crural,  then  follows  in  order  of  frequency  the 
ilio-inguinal  and  ilio-hypogastric,'  which  are  usually  implicated  at  the 
same  time;  obturator  neuralgia  is  an  exceedingly  rare  affection. 

The  character  of  the  pain  presents  no  peculiarities  apart  from  those 
described  in  other  forms.  When  the  pain  is  very  severe  in  one  branch  of 
the  plexus,  it  is  the  rule  to  observe  irradiation  into  some  of  the  other 
branches  at  the  height  of  the  paroxysm.  Exquisite  hyperassthesia  of  the 
integument,  so  that  the  patient  winces  at  the  slightest  touch,  often  devel- 
ops in  the  distribution  of  the  affected  nerve. 

In  neuralgia  of  the  ilio-inguinal,  the  pain  darts  into  the  scrotum  in  the 
male  and  the  labium  major  in  the  female;  this  variety  is  often  attended 
with  frequent  and  painful  micturition.  I  have  noticed  this  symptom  in 
males  as  well  as  in  females.  Various  puncta  dolorosa  have  been  described, 
but  I  have  been  unable  to  discover  any  in  several  cases  of  this  kind,  with 
the  exception  of  the  spinal  point  near  the  first  lumbar  vertebra. 

In  crural  neuralgia  the  pain  is  felt  in  the  distribution  of  the  internal  and 
middle  cutaneous  nerves  to  the  anterior  and  inner  aspects  of  the  thigh, 
and  sometimes  the  inner  part  of  the  leg  and  foot  as  far  forward  as  the 
great  toe.  The  painful  points  are  found  at  the  middle  of  the  groin  where 
the  nerve  passes  out  of  the  pelvis  from  underneath  Poupart's   ligament, 

'  The  lumbar  plexus  is  formed  by  the  anterior  branches  of  the  four  upper  lumbar 
nerves.  It  divides  into  the  ilio-hypogastric,  ilio-inguinal,  genito-crural,  external  cuta- 
neous, obturator,  and  anterior  crural,  the  cutaneous  branches  of  which  are  distributed 
as  foUows  :  the  ilio-hypogastric  to  the  gluteal  region,  midway  between  the  anterior 
and  posterior  spinous  processes  of  the  ilium,  and  to  the  hypogastric  region ;  the  ilio- 
inguinal to  the  scrotum  and  upper,  inner  part  of  the  thigh  in  the  male,  and  the  labia 
in  the  female  ;  the  genito-crural  to  the  upper  and  anterior  portion  of  the  thigh  ;  the 
external  cutaneous  to  the  outer  side,  and  outer  portion  of  the  anterior  aspect  of  the 
thigh,  nearly  to  the  knee ;  the  obturator  to  the  inner  side  of  the  thigh  above  the  knee. 
The  anterior  crural  has  two  cutaneous  branches,  the  middle  and  internal  cutaneous, 
the  former  being  distributed  to  the  anterior  aspect  of  the  thigh  as  far  as  the  knee,  the 
latter  to  the  inner  aspect  of  the  thigh,  leg,  and  foot  as  far  forward  as  the  great  toe. 


148  FUNCTIONAL    NERVOUS    DISEASES. 

and  at  the  inner  side  of  the  knee-joint.  In  rare  instances  herpes  zoster 
occurs  in  crural  neuralgia.  In  severe  cases  the  limb  is  held  motionless 
as  in  sciatica,  to  prevent  an  increase  in  the  severity  of  the  painful  par- 
^oxysms.  It  is  unnecessary  to  give  the  symptoms  of  each  form  in  detail; 
they  merely  differ  with  regard  to  the  distribution  of  the  pain. 

A  good  example  of  this  variety  of  neuralgia,  and  which  at  the  same 
time  illustrates  the  frequent  dependence  of  the  disease  upon  other  affec- 
tions, is  shown  in  the  following  case,  which  I  saw  in  consultation  with  Dr. 
John  Munn,  of  this  city,  to  whose  kindness  I  am  indebted  for  the  follow- 
ing notes: 

Case  V. — S.  L.,  aet.  23  years;  a  kept  mistress;  no  neuropathic 
tendency  in  the  family.  The  patient  took  cold  during  her  first  menstrua- 
tion (at  the  age  of  fourteen)  and  this  was  immediately  followed  by  severe 
pain  in  the  distribution  of  the  middle  and  external  cutaneous  nerves  of 
the  right  lower  limb.  The  pain  was  sharp  and  excruciating,  much  worse 
at  night,  and  lasted  for  three  months.  After  this,  "  catching  cold  "  would 
cause  the  pain  to  reappear;  she  was  never  worse  during  menstruation. 
In  1877,  her  physician  thought  she  had  some  uterine  trouble,  and  sent 
her  to  Hot  Springs,  where  she  had  a  very  severe  attack  of  neuralgia. 
In  1878  she  was  treated  by  Drs.  Briddon  and  Seguin  during  a  very  bad  at- 
tack lasting  nearly  three  months,  but  with  very  little  benefit  from  the  treat- 
ment (morphine  and  galvanism).  The  patient  came  under  Dr.  Munn's 
care  on  April  1,  1879.  Upon  examination,  signs  of  endocervicitis  were 
found  present,  and  the  uterus  was  slightly  retroverted  and  a  little  lower 
down  in  the  pelvis  than  normal.  There  was  some  tenderness  on  pres- 
sure to  the  right  of  the  uterus  anteriorly.  Applications  were  made  to 
the  OS  uteri  for  a  month,  with  marked  improvement  in  the  condition  of 
the  organ;  the  neuralgic  symptoms  improved  at  the  same  time,  although 
they  were  not  treated  directly. 

June  1st. — The  pain  again  returned  in  a  very  severe  form,  after  in- 
dulgence in  sexual  intercourse,  which  had  been  interdicted.  I  saw  the 
patient  in  consultation  on  June  15th;  the  pain  was  of  an  excruciating 
character,  and  confined  to  the  anterior  and  lateral  aspects  of  the  right 
thigh,  extending  nearly  to  the  knee;  it  was  of  a  shooting  character,  but 
unattended  with  hyperassthesia  or  trophic  disturbances;  no  painful  points 
along  the  spine.  Cervical  catarrh  again  present,  and  tenderness  felt 
upon  pressing  deeply  into  the  abdomen  on  the  right  side  over  the  brim 
of  the  pelvis  about  midway  between  the  symphysis  and  sacrum.  Pres- 
sure at  this  point  sometimes  gave  rise  to  shooting  pains  down  the  thigh. 

I  advised  the  continuance  of  the  local  treatment  of  the  uterus,  to- 
gether with  the  internal  administration  of  Fowler's  solution  and  aconitia, 
gr.  yJ-g-  night  and  morning,  in  increasing  doses  until  the  physiological  ef- 
fects are  produced. 

July  1st. — The  pain  has  ceased  and  her  condition  is  excellent;  treat- 
ment with  arsenic  continued.  The  patient  then  went  to  Saratoga  for  the 
summer,  and  remained  well,  with  the  exception  of  a  few  occasional 
twinges,  until  October  1st.  The  pain  now  returned  in  a  very  violent 
form,  and  persisted  with  a  few  intermissions  until  November  11th.  She 
was  then  seen  by  Dr.  Thomas  in  consultation,  who  found  slight  retrover- 
sion of  the  uterus.  Dr.  Thomas  believed  that  the  neuralgia  was  due  to 
some  obscure  neurosis,  and  that  the  uterine  disorder  Avas  only  a  partial 
cause;  he  advised  replacement,  but  expected  no  good  from  it. 

Toward  the  end  of  November  I  again  saw  the  patient  in  consultation. 


NEURALGIA.  149 

The  pain  was  now  of  a  frightful  character,  and  could  only  be  controlled 
by  immense  doses  of  morphine,  as  mucli  as  100  minims  of  Magendie's  so- 
lution having  been  administered  on  one  occasion  within  three  hours. 
The  patient  was  in  an  extremely  hysterical  condition,  which  was  partly 
due  to  continual  worry  from  the  belief  that  she  was  about  to  be  discarded 
by  her  lover. 

A  large  number  of  remedies  had  been  resorted  to  in  succession  (bro- 
mide of  potassium,  atropine,  aconitia,  strychnine,  blisters,  etc.)  in  he- 
roic doses,  but  ijot  the  slightest  benefit  was  obtained.  A  tolerable  amount 
of  relief  was  only  afforded  by  hypodermics  of  morphine.  On  December 
9th  the  patient  started  for  Baltimore,  the  pain  having  subsided  some- 
what during  the  last  week;  this  is  probably  due  to  the  fact  that  the 
cause  of  her  mental  worry  has  been  removed.  Since  that  time  the  pa- 
tient has  felt  perfectly  well. 

This  case  is  interestisg  from  several  points  of  view.  In  my  opinion 
the  chief  cause  of  the  protracted  character  of  the  disease  was  the  hys- 
terical condition,  induced  by  leading  a  life  of  luxury,  with  no  object  in 
view  save  pleasure.  I  am  also  convinced  that  the  uterine  disorder  was  a 
potent  etiological  factor;  it  is  quite  probable  that  the  patient  suffered 
from  mild  pelvic  peritonitis  during  her  first  menstrual  epoch,  and  that 
some  slight  inflammatory  products  remained  in  the  pelvis  and  acted 
partly  as  the  exciting  cause  of  the  neuralgia. 

Etiology. 

This  form  of  neuralgia  is  so  infrequent,  that  very  little  is  definitely 
known  with  regard  to  its  etiology.  It  may  be  due  to  carcinoma,  spon- 
dylitis deformans,  or  caries  of  the  lumbar  vertebrae,  or  to  growths  of  va- 
rious kinds  in  the  pelvis.  In  one  of  my  patients  crural  neuralgia  fol- 
lowed a  forceps  delivery.  In  a  considerable  proportion  of  the  cases  it 
appears  to  be  of  a  reflex  nature,  due,  as  Mauriac  has  shown,  to  orchitis 
or  epididymitis;  it  may  also  be  connected  with  uterine  disease,  as  in  the 
case  reported  above.  1  have  also  seen  a  few  examples  of  ilio-inguinal  neu- 
ralgia in  male  patients  who  were  victims  of  "  nervous  debility "  and 
the  general  lowering  of  morale  which  occurs  when  the  individual  is  suf- 
fering from  seminal  emissions  and  its  accompanying  train  of  symptoms. 
This  is  not  infrequently  combined  with  neuralgia  of  the  testis,  an  ex- 
tremely distressing  malady.  Neuralgia  of  the  obturator  nerve  has  been 
observed  in  obturator  hernia,  and  the  occurrence  of  the  former  should 
always  lead  to  a  careful  examination  with  regard  to  the  presence  of  the 
latter.  Perhaps  the  majority  of  cases  of  lumbar  neuralgia  are  found  to 
develop  during  severe  paroxysms  of  sciatica,  and  in  this  event  the  mid- 
dle and  internal  cutaneous  nerves  (branches  of  the  crural)  are  usually  the 
ones  involved.  In  some  instances,  indeed,  the  lumbar  neuralgia  which 
has  begun  under  such  circumstances  acquires  an  independent  existence, 
and  becomes  even  more  formidable  than  the  primary  sciatica.  Finally, 
a  small  number  of  cases  have  been  reported,  in  which  the  disease  was  ap- 
parently due  to  exposure  or  to  overexertion  of  some  of  the  lumbar  muscles. 

Diagnosis. 

Lumbar  neuralgia  must  be  differentiated  from  myalgia  of  the  lum- 
bar muscles  or  lumbago;  the  character  of  the  pain,  its  distribution,  the 
inability  to  move  the  affected  muscles  without  producing  severe  suffer- 


150  FUNCTIONAL    NEEVOTJS    DISEASES. 

ing,  and  the  consequent  fixed  position  of  the  trunk,  and  the  absence  of 
puncta  dolorosa,  are  sufficient  to  exclude  neuralgia.  In  rare  cases,  how- 
ever, lumbago  is  combined  with  lumbar  neuralgia,  as  in  a  patient  recently 
under  my  observation,  in  whom  lumbago  of  long  standing  became  com- 
plicated with  neuralgia  of  the  ilio-inguinal  nerve.  Myalgia  of  the  ante- 
rior thigh  muscles  may  also  be  mistaken  for  crural  neuralgia,  but  atten- 
tion to  the  symptoms  mentioned  above  will  prevent  error. 

The  latter  form  may  also  be  mistaken  for  morbus  coxae  or  neuralgia  of 
the  hip-joint  (Brodie's  joint),  but  we  shall  enter  into  this  subject  at  some 
length  under  the  head  of  sciatica  (page  158),  which  is  also  liable  to  be 
confounded  with  these  two  affections. 

One  of  the  main  indications  in  making  the  diagnosis  is  to  determine 
the  nature  of  the  primary  lesion.  In  all  cases  in  which  a  definite  cause 
is  unknown,  the  lumbar  spine  and  pelvis  should  be  subjected  to  careful 
physical  exploration.  The  etiological  factors  vary  but  little  from  those 
which  we  have  described  with  reference  to  neuralgias  of  the  upper  limb 
(with  the  exception  of  its  occurrence  in  uterine  affections),  so  that  we 
may  refer  to  the  remarks  on  diagnosis  under  that  head.  Before  affirming 
the  existence  of  any  connection  between  a  uterine  affection  and  some  form 
of  lumbar  neuralgia,  we  should  satisfy  ourselves  that  the  latter  improves, 
pari  2ycissu,  with  the  former,  and  has  followed  it  in  point  of  time.  We 
must  not  forget,  also,  that  both  affections  may  be  the  expression  of  de- 
pressed vitality  of  the  general  sj'stem. 


Treatment. 

Fortunately  this  disease  does  not  often  assume  extreme  severity. 
The  indications  for  rational  treatment  can  very  rarely  be  met.  In  cases  of 
spondylitis  or  caries  of  the  spine,  and  in  uterine  disease,  the  appropriate 
treatment  for  these  affections  may  prove  useful,  but  in  the  majority  of 
cases  we  must  rely  chiefly  on  symptomatic  measures. 

Counter-irritation,  in  the  form  of  fly-blisters  applied  over  the  painful 
spots  at  the  exit  of  the  affected  nerve  from  the  lumbar  spine,  is  of  decided 
advantage.  It  should  be  applied  more  vigorously  than  in  intercostal 
neuralgia,  as  the  nerves  are  farther  removed  from  the  integument.  The 
actual  cautery  may  also  be  used,  preferably  along  the  course  of  the  cu- 
taneous distribution  of  the  nerve.  The  chief  reliance  must  be  placed 
upon  the  use  of  morphine,  when  the  pain  is  intolerable,  and  upon  the 
steady  application  of  the  continuous  current.  In  employing  the  latter 
one  electrode  is  placed  at  the  exit  of  the  nerves  from  the  lumbar  spine, 
the  other  upon  some  portion  of  their  external  course.  The  current  should 
possess  considerable  intensity,  as  the  nerves  are  situated  deeply,  and  are 
therefore  not  readily  affected  by  electricity.  I  should  also  mention  that 
in  the  case  of  lumbago  and  ilio-inguinal  neuralgia  to  which  I  have  referred, 
and  which  had  caused  constant  and  severe  suffering  for  a  year,  relief  was 
very  quickly  obtained  by  the  use  of  the  faradic  current,  applied  over  the 
painful  parts.  Internal  remedies  have  not  appeared  to  be  of  much  ser- 
vice. In  my  own  hands  the  greatest  amount  of  relief  has  been  obtained 
from  the  use  of  strychnia,  beginning  in  doses  of  gr.  -^,  t.i.d.,  and  gradu- 
ally increasing  until  physiological  effects  are  obtained.  Sometimes,  as 
occurred  in  the  case  reported  on  page  148,  abundant  opportunity  will  be 
afforded  us  to  experiment  in  succession  with  a  considerable  proportion  of 
the  neurotics  contained  in  the  materia  medica. 


CHAPTER  XI. 

SCIATICA. 
Clinical  History. 

This  form  of  neuralgia  ranks  next  to  that  of  the  trigeminus  in  impor- 
tance and  interest,  on  account  of  its  severity  and  frequency.  The  disease 
usually  begins  with  prodromata,  consisting  of  a  feeling  of  heaviness  in  the 
limb,  numbness  and  tingling,  or  a  sensation  of  coldness.  Exceptionally 
a  paroxysm  begins  suddenly,  and  in  one  instance  I  saw  a  patient  (who 
had  never  suffered  from  any  form  of  neuralgia  previously),  in  whom  one 
of  the  most  violent  paroxysms  which  I  have  ever  seen,  developed  im- 
mediately after  rising  from  a  kneeling  posture.  The  pain  is  of  a  markedly 
lancinating,  darting  character,  and  may  involve  the  entire  course  of  the 
nerve;  it  usually  darts  toward  the  periphery,  but  sometimes  shoots  up  and 
down  the  nerve  with  intolerable  violence.  It  is  sometimes  so  intense  as 
to  cause  even  the  bravest  patient  to  cry  out  in  agony  and  to  roll  on  the 
floor  in  despair.  In  one  of  my  cases  the  pain  was  so  severe,  notwithstand- 
ing the  hypodermic  injection  of  a  very  large  dose  of  morphine,  that  I 
could  only  restrain  the  patient  by  main  force  from  committing  suicide. 
But  these  cases  are  very  rare,  nor  do  we  find,  save  in  exceptional  in- 
stances, that  the  hysterical,  broken-down  condition  of  mind  is  produced 
which  is  met  with  in  bad  cases  of  trigeminal  neuralgia.  In  the  begin- 
ning of  the  affection  the  pain  is  very  commonly  limited  to  the  upper  part 
of  the  course  of  the  nerve,  and  after  a  while  it  spreads  to  the  lower 
branches.  But  the  reverse  also  holds  good,  and  individual  branches  (per- 
haps such  a  small  twig  as  the  plantar  nerve)  may  be  alone  affected 
throughout  the  entire  course  of  the  disease.  If  the  patient  is  intelligent 
and  a  good  observer,  he  will  be  able  to  trace  the  course  of  the  nerve  with 
his  finger,  and  this  is  sometimes  done  as  accurately  as  by  a  well-informed 
anatomist. 

Puncta  dolorosa  are  observed  in  nearly  all  cases.  The  most  usual 
sites  in  the  order  of  frequency  are:  a  gluteal  point,  beneath  the  gluteal 
fold,  half-way  between  the  trochanter  major  and  the  tuber  ischii;  a  point 
at  the  emergence  of  the  nerve  from  the  sciatic  foramen ;  a  point  at  the  pos- 
terior superior  spinous  process  of  the  ilium;  one  or  two  popliteal  points,  at 
either  side  of  the  popliteal  space,  immediately  within  the  hamstrings;  a 
fibular  ^o\nt^  behind  the  head  of  the  fibula;  two  ?na/^eoter  points,  at  the  pos- 
terior part  of  each  malleolus.  ^\\q point  apophysaire  is  not  by  any  means 
so  common  as  the  puncta  dolorosa,  and  its  distribution  varies  somewhat, 
tenderness  being  sometimes  appreciable  over  one  or  more  of  the  sacral 
vertebra,  and  at  times  over  the  first  and  second  lumbar  vertebrae.  We 
not  infrequently  find,  especially  in  those  cases  in  which  there  is  consid- 
erable dull  pain  in  the  intervals  of  the  paroxysms,  that  the  entire- length 
of  the  nerve  is  sensitive  to  pressure. 


152  FUNCTIONAL    NERVOUS    DISEASES. 

The  pain  is  usually  confined  to  one  nerve,  but  in  some  cases  both 
are  involved,  even  when  the  disease  is  not  connected  with  any  affection  of 
the  spinal  cord.  But  we  should  always  be  careful  to  exclude  diseases  of 
the  spinal  cord  or  its  membranes  whenever  we  are  brought  in  contact  with 
a  case  of  bilateral  sciatica. 

Patients  suffering  from  severe  forms  of  this  disease  are  generally  con- 
fined to  their  back.  The  slightest  movement  of  the  limb,  the  act  of  defe- 
cation, coughing,  sneezing,  sitting  down,  and  sometimes  the  mere  con- 
tact of  the  bedclothes  with  the  affected  leg  will  prove  sufficient  to  pro- 
duce a  paroxysm  of  pain.  In  severe  cases,  the  pain  is  often  irradiated  to 
the  distribution  of  other  nerves,  usually  the  crural,  though  even  more  dis- 
tant nerves,  such  as  the  trigeminus,  may  be  thus  affected.  The  irradiated 
pain,  however,  never  attains  the  severity  of  the  primary  affection. 

When  the  pain  is  severe,  disturbances  of  sensation  are  usually  well 
marked.  In  the  beginning  of  the  attack  we  generally  meet  with  hyper- 
lesthesia  of  the  skin,  which  may  be  either  localized  in  small  spots  or  dif- 
fused over  the  entire  distribution  of  the  nerve.  In  some  cases  the  hyper- 
jesthesia  is  so  well  marked  that  the  slightest  contact  with  the  skin  is 
agonizing  to  the  patient,  so  that  he  cannot  even  bear  the  weight  of  the 
bedclothes.  x\fter  the  disease  has  lasted  for  a  long  time  anaesthesia  de- 
velops and  is  sometimes  very  pronounced.  Very  frequently,  also,  we  may 
notice  spots  of  hypersesthesia  and  of  anaesthesia  on  the  limb  at  the  same 
time. 

Sciatica  presents  important  and  interesting  motor  complications,  which 
are  usually  manifested  only  in  cases  that  attain  considerable  severity. 
Fibrillary  twitchings  are  not  uncommonly  observed,  especially  in  the  calf 
muscles  and  those  of  the  back  of  the  thigh.  At  times  these  muscular 
twitchings  become  more  widespread,  and  the  whole  limb  is  thrown  into 
clonic  convulsions;  these  are  only  observed  at  the  height  of  the  paroxysm, 
and  soon  subside.  In  one  extremely  severe  case  the  whole  body  was  thrown 
into  violent  convulsions  (not  preceded  by  tonic  spasm  and  unattended 
with  loss  of  consciousness),  but,  as  the  patient  had  been  drinking  whiskey 
very  freely  (this  appeared  to  be  the  exciting  cause  of  the  sciatica),  I  am 
unable  to  state  positively  whether  the  convulsions  were  the  result  of  the 
neuralgic  affection  or  not. 

Contracture  sometimes  occurs  at  the  knee-joint.  We  do  not  now  re- 
fer to  the  voluntary  stiffness  of  the  limb  assumed  by  the  patient  in  order 
to  prevent  pain,  but  to  a  rigidity  of  the  hamstring  muscles,  which  cannot  be 
overcome  by  any  reasonable  exercise  of  muscular  power,  either  on  the  part  of 
the  patient  or  the  physician.  The  knee  may  be  bent  at  quite  a  sharp  an- 
gle, and  the  contracture  may  persist  for  several  weeks  or  even  longer;  it 
does  not  disappear  during  sleep. 

The  gait  in  severe  cases  is  peculiar.  The  patient  in  walking  keeps 
the  limb  slightly  flexed  at  the  knee,  and  walks  on  the  toes  of  the  affected 
foot.  The  gait  is  stiff  and  awkward,  and  the  patient  favors  tiie  sound 
limb.  The  entire  muscular  tissues  of  the  limb  sometimes  atrophy.  The 
amount  of  wasting  is  usually  slight,  and  is  due  to  the  comparative  disuse 
of  the  limb  occasioned  by  the  severe  pain.  But,  in  exceptional  cases,  the 
muscular  atrophy  is  excessive,  and  cannot  be  accounted  for  in  this  man- 
ner. We  must  therefore  fall  back  upon  the  supposition  that  it  is  a 
trophic  change,  due  to  the  implication  of  the  trophic  fibres  contained  in  the 
nerve-trunk  by  the  morbid  process  which  has  given  rise  to  the  neuralgia. 

Hypertrophy  of  the  muscles  of  the  thigh  and  calf  has  also  been  ob- 
served in  one  case. 


NEURALGIA.  153 

The  following  history,  the  notes  of  which  were  obtained  through  the 
kindness  of  my  house  pliysician,  Dr.  Wyrnan,  exemplifies  most  of  the 
motor  disorders  observed  in  severe  forms  of  sciatica. 

Case  VI. — Wm.  Schmidt,  a3t.  30  years;  single;  admitted  to  Randall's 
Island  Hospital,  September  25,  1879;  family  history  good,  never  had 
rheumatism,  denies  venereal.  The  patient  always  enjoyed  good  health 
prior  to  this  disease.  In  November,  1877,  he  was  shipwrecked,  and  com- 
pelled to  remain  in  the  water  for  twenty-four  hours.  About  six  weeks 
after  this  exposure  he  began  to  have  pain  in  the  left  gluteal  region,  which 
extended  down  the  back  of  the  thigh,  following  the  course  of  the  sciatic 
nerve.  The  pain  was  increased  very  much  during  bad  weather,  so  that 
he  often  had  to  take  to  his  bed.  Not  obtaining  relief,  he  was  admitted  to 
the  Homoeopathic  Hospital,  Ward's  Island,  and  after  remaining  there  three 
months  unimproved,  the  surgeon  cut  down  upon  the  sciatic  nerve  and 
stretched  it.  After  this  operation  the  patient  says  his  pains  were  very 
much  increased,  and  he  was  never  free  from  them  except  while  under  the 
influence  of  an  opiate.  He  was  discharged  unimproved  at  the  end  of  six 
months. 

March  29,  1879,  he  was  admitted  to  Charity  Hospital,  Jersey  City, 
where  the  wound  made  by  the  operation  for  nerve-stretching  healed,  but 
the  sciatica  did  not  improve.  He  was  treated  with  the  actual  cautery  along 
the  course  of  the  nerve;  the  patient  remained  there  two  months,  and  was 
then  admitted  to  Randall's  Island  Hospital. 

On  admission  his  general  condition  was  poor;  he  complained  of 
intense  paroxysms  of  shooting  pain  (which  forced  him  to  whimper) 
along  the  entire  course  of  the  left  sciatic  nerve,  and  which  were  greatly 
heightened  by  the  slightest  movement  of  the  limb.  The  pain  was  so  se- 
vere that  he  was  compelled  to  keep  to  bed  constantly.  There  were  fre- 
quent fibrillary  twitchings  in  the  muscles  of  the  back  of  the  thigh,  and 
marked  atrophy  of  the  muscles  of  the  affected  limb  (unfortunately  no 
record  was  kept  of  the  difference  in  the  measurements  of  the  two  limbs, 
but  I  have  a  distinct  recollection  that  the  affected  thigh  was  at  least 
one  and  a  half  to  two  inches  less  in  circumference  than  the  healthy  one). 
Aconitia,  gr,  Jg^  t.i.d.,  was  ordered,  to  be  gradually  increased  until  the 
physiological  effects  were  obtained.  This  treatment  was  continued  until 
October  2Gth,  and  produced  slight  improvement. 

October  27th. — Ordered  strychnite  sulph.,  gr.  -j'^,  t.i.d.,  to  be  increased 
one  dose  daily  until  the  full  effects  of  the  drug  were  obtained. 

November  5th. — Since  the  administration  of  the  strychnia,  his  general 
condition  has  improved  very  much;  he  has  a  fine  appetite,  and  has  gained 
in  flesh.  He  is  often  comparatively  free  from  pain,  and  rests  well  at 
night.  At  varying  intervals,  which  have  been  longer  in  duration  since 
the  use  of  strychnia  was  begun,  severe  paroxysms  were  felt.  At  such 
times  the  hypodermic  administration  of  morphia  has  been  resorted  to 
with  good  effect.  He  is  at  present  taking  gr.  ^  of  strychnia  daily,  this 
treatment  was  continued  until  November  29th,  with  several  intermissions 
of  a  few  days  each,  whenever  the  physiological  effects  of  the  drug  were 
too  pronounced.  The  duration  of  the  intervals  between  the  paroxysms 
was  considerably  increased,  but  the  pain  felt  during  the  latter  was  still 
extremely  severe. 

December  2d. — Ordered  atropine  sulph.,  gr.  ^^,  t.i.d.,  to  be  increased 
one  dose  daily. 

December   Gth. — The  patient  received   six   doses  of  atropia  (gr.  -^j) 


154  FUNCTIONAL    ISTEEVOUS    DISEASES. 

yesterday;  this  morning  he  has  dryness  of  the  throat,  and  disturbance  of 
vision;  pupils  dilated.  He  has  not  had  a  paroxysm  of  severe  pain  since 
the  administration  of  the  drug  was  commenced.  The  paroxysms  then 
appeared  again,  and  the  atropia  was  continued  until  .January  10th,  with 
several  intermissions  of  a  few  days  each.  The  patient  now  feels  much 
better,  except  when  he  moves  the  affected  limb.  For  the  past  few  weeks 
the  limb  has  been  contractured  at  the  knee-joint;  the  contracture  could 
not  be  overcome  by  the  patient  or  by  myself,  on  account  of  the  severe 
pain  to  which  such  attempts  gave  rise.  To  relieve  this  symptom,  hot 
sitz-baths  were  ordered. 

January  6th. — The  patient  experiences  a  good  deal  of  relief  from  the 
baths.  The  hamstring  muscles,  which  were  formerly  contracted,  are  now 
becoming  relaxed,  so  that  the  leg  can  be  extended  without  producing  pain. 

January  20th. — The  patient  is  improving  rapidly;  he  is  up  and  about 
the  ward,  but  has  to  walk  with  crutches. 

January  28th. — Crutches  taken  away;  patient  walks  with  a  stick,  and 
has  slight  pains  in  locomotion. 

February  2d. — Patient  walks  now  without  difficulty;  the  pains  have 
entirely  disappeared.  The  muscles  of  the  affected  limb  have  regained 
the  greater  part  of  their  natural  strength  (no  measurements  were  taken). 
The  patient's  general  condition  is  excellent.  Discharged  cured,  and  has 
since  gone  to  work. 

The  other  complications  of  sciatica  are  infrequent  and  unimportant. 
In  some  cases  the  limb  is  hot  and  perspiring,  in  others  the  skin  is  dry  and 
brittle;  the  integument  may  be  of  a  uniform  red  color  or  mottled  in  ap- 
pearance; sometimes  it  is  paler  and  cooler  than  the  other  limb.  Glyco- 
suria constitutes  the  most  interesting  of  the  vaso-motor  complications  of 
sciatica,  although  very  few  observations  have  been  made  on  this  subject. 

Schiff  had  shown  that  section  of  the  sciatic  or  other  large  nerve-trunks 
in  certain  of  the  lower  animals  was  capable  of  producing  mellituria,  and 
this  physiologist,  as  well  as  others  who  have  corroborated  his  experi- 
ments, have  regarded  the  symptom  as  due  to  reflex  paralysis  of  the  vaso- 
motor nerves  supplying  the  liver.  Braun  '  found  several  cases  of  sci- 
atica in  which  sugar  was  demonstrable  in  the  urine,  and  the  correctness 
of  his  observation  has  been  since  verified  by  Rosenbach,  Though  the 
histories  of  these  cases  are  unsatisfactory,  it  appears  that  they  never 
lead  to  true  diabetes,  but  only  to  a  temporary  mellituria.  The  presence 
of  sugar  in  the  urine  in  such  cases  has  been  explained  in  the  same 
manner  as  Schiff's  cases  of  experimental  diabetes,  but  this  view  is  purely 
hypothetical,  and  further  investigation  may  cause  a  change  of  opinion  in 
this  respect.  The  subject  is  very  interesting,  and  one  which  is  worthy  of 
thorough  and  continued  research. 


Etiologt. 

The  etiology  of  sciatica  is  well  defined  by  Eulenburg  when  he  calls  it 
"  the  type  of  peripheral,  accidental  neuralgias." 

Anstie  observed  four  cases  in  which  heredity  played  an  important 
part,  but  this  is  probably  an  exceptional  experience.  Many  authors 
scarcely  mention  heredity  as  one  of  the  etiological  factors  in  this  affec- 

'  Syatematiches  Lehrbucb  der  Balneotherapie,  1868, 


NEURALGIA.  155 

tion,  and  all  are  agreed  that  it  has  very  little  influence  in  this  direc- 
tion. 

The  disease  is  very  infrequent  in  childhood,  and  Soltmann,^  the  latest 
writer  on  the  subject,  has  not  met  with  a  single  example  at  this  period  of 
life.  The  majority  of  the  cases  occur  between  the  ages  of  twenty  to 
fifty  years,  but  the  affection  develops  not  infrequently  long  after  the  lat- 
ter age,  three  of  my  cases  beginning  at  the  ages  of  sixty-eight,  seventy, 
and  seventy-four  years  respectively. 

According  to  the  united  testimony  of  the  majority  of  authors,  the 
male  sex  is  much  more  subject  to  sciatica  than  the  female,  and  in  my  own 
cases  the  proportion  has  been  as  one  to  two  and  a  half.  Arnoldi,  who 
has  furnished  the  largest  statistics  on  the  subject,  finds  that  females  were 
affected  almost  as  frequently  as  males  (173  males,  1G6  females),  but  this 
statement  is  entirely  opposed  to  the  common  experience  of  physicians. 

The  majority  of  the  causes  which  give  rise  to  sciatica  are  those  which 
act  upon  the  nerve  after  its  exit  from  the  spinal  canal.  The  lesion  may, 
however,  be  situated  in  the  bones  of  the  spinal  column  or  within  the 
canal.  This  category  includes  spondylitis  deformans,  cancer  of  the  ver- 
tebrfe,  or  the  presence  of  gummata  which  have  grown  from  the  dura 
mater  or  from  the  vertebras  themselves.  These  various  lesions  act  by 
simply  producing  pressure  upon  the  roots  of  the  nerve,  and  the  neuralgia 
caused  thereby  is  of  a  peculiarly  lancinating  character.  In  very  rare  in- 
stances false  and  even  true  neuromata  have  been  found  within  the  spinal 
canal  and  growing  upon  the  Cauda  equina.  J^  may  also  be  produced  by 
numerous  processes  situated  within  the  pelvic  cavity,  both  in  the  male 
and  female.  Any  affection  which  interferes  with  the  return  of  venous 
blood  from  the  pelvis  will  predispose  to  its  development.  The  sciatic 
nerve  is  surrounded  by  a  large  number  of  veins,  the  greater  part  of  which 
constitute  the  hemorrhoidal  plexus.  These  veins  are  large,  wide-meshed, 
and  possess  no  valves,  so  that  an  obstacle  to  the  flow  of  blood  in  them 
will  very  readily  give  rise  to  a  varicose  condition,  and  consequently  to 
pressure  upon  the  nerve.  Such  an  obstacle  may  be  due  to  cirrhosis  of 
the  liver,  or  to  any  other  disease  of  that  organ  or  of  adjacent  parts  which 
will  interfere  with  the  portal  circulation.  Within  the  pelvis  itself  this 
condition  may  be  due  to  pregnancy,  to  the  use  of  forceps  during  delivery, 
to  the  growth  of  intra-pelvic  tumors,  to  exudations  into  the  broad  liga- 
ments or  into  Douglas'  cul-de-sac,  or  to  an  accumulation  of  hardened 
fseces  in  the  rectum.  It  has  been  doubted  by  some  writers  whether  the 
latter  cause  is  ever  capable  of  producing  pressure  upon  the  sciatic  nerve, 
but  a  case  which  was  recently  under  my  observation  is,  to  my  mind,  con- 
clusive in  this  regard.  The  patient  in  question  had  had  no  evacuation 
for  twelve  days,  and  complained  of  formication  and  anaesthesia,  which 
was  confined  to  the  exact  distribution  of  the  left  sciatic  nerve.  The 
exhibition  of  a  purge,  which  produced  a  free  passage,  caused  these 
symptoms  to  disappear  entirely.  It  is  difficult  to  determine,  however, 
whether  the  causes  we  have  just  mentioned  act  by  pressing  directly  upon 
the  nerve  or  by  producing  dilatation  of  the  hemorrhoidal  plexus  and 
secondary  pressure  in  this  manner. 

In  the  course  of  the  nerve  outside  of  the  pelvic  cavity,  there  are  also 
numerous  lesions  capable  of  producing  sciatida.  This  category  includes 
injuries  to  the  nerve,  such  as  those  produced  by  gunshot  wounds  (which 
are  very  rarely  met  with  except  in  military  surgery),  wounds  made  by  the 

'  Gerhardt's  Handbuch  der  Kinderkrankh. 


156  FUNCTIONAL    NEEVOUS    DISEASES. 

lancet  in  venesection  (not  very  infrequent  formerly,  but  never  observed  at 
present),  blows  from  blunt  instruments,  falls  on  the  buttocks,  popliteal 
aneurism,  neuromata,  syphilitic  and  other  tumors  of  the  nerve  itself  or 
of  surrounding  tissues.  Those  cases  which  are  attributed  to  severe  mus- 
cular strain  should  be  included  under  the  head  of  injury  to  the  nerve.^ 
Some  writers  are  skeptical  with  regard  to  the  efficacy  of  this  cause,  but 
one  of  the  most  severe  cases  of  sciatica  which  has  come  under  my  obser- 
vation occurred  in  a  robust  farm-hand,  immediately  after  lifting  a  heavy 
beam.  At  the  time  of  the  accident  he  "  felt  something  crack  "  in  the 
lower  part  of  the  back,  and  immediately  began  to  suffer  from  intense 
pains  along  the  sciatic  nerve  which  resisted  all  treatment  for  upward  of 
a  year. 

Cotugno  had  called  attention  to  the  fact  that  sciatica  prevails  endemi- 
cally  in  the  neighborhood  of  Naples,  and  that  this  circumstance  is  ex- 
plained by  atmospheric  influences.  There  is  no  doubt  that  the  affection 
is  more  apt  to  develop  in  moist,  windy  weather,  and  the  severity  of  an 
attack  always  increases  under  such  conditions.  Exposure  to  atmospheric 
changes  also  explains  the  comparative  frequency  of  sciatica  in  those  whose 
occupation  requires  them  to  be  exposed  to  all  kinds  of  weather.  I  have 
noticed  this  especially  in  coachmen,  but  in  this  class  two  causes  may  co- 
operate in  the  production  of  the  disease,  viz.,  the  exposure  to  changes  of 
weather,  and  the  constant  sitting  position  which  the  patients  are  com- 
pelled to  assume,  and  in  which  the  sciatic  nerve  may  be  pressed  upon  by 
the  projecting  seat.  • 

Sciatica  is  not  often  due  to  constitutional  causes,  and  differs  in  this 
respect  from  other  forms  of  neuralgia.  As  a  rule  the  patients  are  not 
anaemic  at  the  beginning  of  the  disease,  although  this  condition  is  readily 
produced  after  the  sciatica  has  lasted  for  some  time,  on  account  of  the 
depressing  influence  of  the  pain,  the  lack  of  exercise,  etc.  But  we  find 
that  sciatica  not  infrequently  develops  in  old  age,  after  degeneration  of 
the  vessels  has  begun,  although  this  is  not  of  such  frequent  occurrence, 
by  any  means,  as  in  the  case  of  trigeminal  neuralgia.  In  such  an  event 
the  disease  may  continue  uninterruptedly  until  death. 

Malaria  is  not  so  often  a  cause  of  sciatica  as  it  is  of  other  neuralgias, 
and  is  not  even  mentioned  by  many  neurologists  as  an  etiological  factor. 
According  to  Schramm,  malarial  sciatica  usually  affects  the  entire  trunk 
of  the  nerve  (usually  the  right),  and  in  rare  cases  is  bilateral.  In  one 
case  under  my  observation  the  pain  took  the  place  of  the  chill,  and  was 
confined  to  the  plantar  branch  of  one  nerve.  It  generally  assumes  the 
quotidian,  but  sometimes  the  tertian  type.  We  must  remember,  how- 
ever, that  malarial  neuralgia  may  sometimes  be  continuous,  and  on  the 
other  hand,  that  the  pain  may  assume  a  pure  intermittent  type,  although 
the  neuralgia  is  due  to  some  other  cause,  or  may  even  be  symptomatic 
of  an  organic  lesion  of  the  nerve.  We  should,  therefore,  not  make  a 
diagnosis  of  malarial  sciatica  unless  other  evidences  of  malarial  infection 
are  present,  or  unless  quinine  exercises  a  specific  influence  upon  its  course. 

Syphilis  is  also  an  infrequent  cause  of  this  disease,  though  it  would 
appear  from  recent  investigations  that  it  is  produced  more  often  in  this 
manner  than  was  formerly  believed.  Fournier  called  attention  to  the 
fact  that  sciatica  may  be  caused  by  the  mere  presence  of  the  syphilitic 
virus  in  the  blood  during  the  early  secondary  stage.  Its  development  in 
this  stage  must,  however,  be  very  rare,  since  it  is  hardly  ever  observed 
even  by  specialists  in  venereal  diseases.  Dr.  R.  W.  Taylor,  of  this  city, 
who  has  written  an  interesting  article  on  syphilitic  sciatica  in  the  I^ew 


NEURALGIA.  157 

York  Medical  Journal,  March,  1880,  has  only  met  with  two  cases  in  tlie 
secondary  stage,  and  Dr.  Keyes  informs  me  that  he  has  not  observed  a 
single  example.  In  the  large  majority  of  cases,  however,  it  is  due  to 
syphilitic  changes  in  the  nerve  itself,  or  to  irritation  or  compression  of  the 
nerve  by  gummy  growths  in  the  adjacent  tissues. 

Considerable  doubt  has  been  cast  upon  the  reported  cases  of  alterna- 
tion of  acute  articular  rheumatism  and  sciatica.  No  instances  have 
come  under  my  own  notice,  and  the  cases  reported  in  the  journals  are 
described  so  unsatisfactorily  that  it  is  difficult  to  arrive  at  a  definite  con- 
clusion in  the  matter.  There  can  be  no  doubt,  however,  that  a  causal 
connection  between  these  two  affections  does  exist  in  rare  instances. 

Fournier  has  reported  seven  cases  of  sciatica  occurring  during  the 
course  of  gonorrhoeal  rheumatism  (which  is  not  a  true  rheumatism),  and 
others  have  been  since  observed.  The  pain  in  this  variety  usually  dis- 
appears with  the  rheumatic  affection. 

Sciatica  has  also  been  attributed  to  gout,  but  it  is  doubtful  whether 
this  does  not  act  merely  as  a  predisposing  cause  on  account  of  the 
abdominal  plethora  which  is  so  common  in  the  latter  affection. 

I  also  \\^ish  to  call  attention  to  the  relation  of  delirium  tremens  to 
sciatica.  Three  of  the  severest  cases  of  sciatica  which  have  come  under 
my  observation  occurred  during  the  first  period  of  a  mild  attack  of 
delirium  tremens,  in  patients  who  had  never  been  previously  subject  to 
neuralgia.  In  all  three  patients  the  disease  was  of  very  short  duration 
(in  one  it  only  lasted  twenty-four  hours),  but  during  this  time  their  tor- 
tures were  terrible.  Relief  could  only  be  obtained  by  the  hypodermic 
injection  of  large  doses  of  morphine. 

Reflex  irritation  possesses  very  little  efficacy  in  the  production  of 
sciatica.  It  sometimes  develops  in  the  course  of  other  neuralgias,  such 
as  trigeminal  or  brachial,  but  it  is  difficult  to  determine  whether  this  is 
the  result  of  a  reflex  irradiation  of  the  pain,  or  the  expression  of  a  gen- 
eral cause.  In  the  larger  number  of  cases  the  source  of  reflex  irritation 
appears  to  reside  in  the  genital  organs.  Mauriac  has  shown  that  it  may 
occur  during  the  course  of  gonorrhoeal  epididymitis.  It  has  also  been 
observed  as  the  result  of  stricture  of  the  urethra  or  of  a  stone  in  the 
bladder.  It  may  be  due  to  a  uterine  disorder  which  has  not  produced 
any  pressure  upon  the  nerve.  A  few  apparently  authentic  cases  have 
been  reported  in  which  sciatica  was  caused  by  the  presence  of  worms  in 
the  intestines. 


Diagnosis  and  Peognosis. 

Sciatica  is  perhaps  more  frequently  mistaken  for  myalgia  of  the  muscles 
of  the  loins  and  thigh  than  for  any  other  form  of  disease.  But  the  latter 
affection  usually  involves  not  alone  the  muscles  of  the  posterior,  but  also  of 
the  anterior  part  of  the  thigh;  in  other  words,  the  pain  is  not  strictly  lim- 
ited to  the  distribution  of  the  sciatic  nerve.  Pancta  dolorosa,  which  fre- 
quently form  such  a  prominent  part  in  the  history  of  sciatica,  are  never 
present  in  myalgia,  and  the  pain  and  tenderness  are  diffused  in  the  latter 
affection,  while  in  sciatica,  as  Valleix  expresses  it,  the  patient  marks  out 
the  course  of  the  pain  with  the  tip  of  the  finger.  The  pain  of  myalgia  is 
always  absent  when  the  limb  is  kept  perfectly  quiet,  while  that  of  sci- 
atica, although  aggravated  by  movement,  also  develops  when  the  leg  is 
motionless.     We  have  previously  referred,  in  the  general  chapter  on  diag- 


158  JFUNCTIOJfAL    NERVOUS   DISEASES. 

nosis,  to  the  characteristics  of  myalgic  pain,  and  these  alone  will  usually 
be  suiBcient  to  enable  us  to  make  a  differential  diagnosis. 

Locomotor  ataxia  is  often  distinguished  with  difficulty  from  sciatica. 
Cases  have  been  reported  in  which  ataxia  was  diagnosed,  although  no  other 
symptom  beyond  that  of  the  ataxic  pains  had  been  observed  for  a  period 
of  even  twenty  years,  and  we  can  therefore  readily  conceive  that  a  differ- 
ential diagnosis  is  often  very  difficult  and  sometimes  even  impossible. 
The  pains  of  ataxia  are  invariably  bilateral,  and  always  of  the  most  marked 
lancinating  character.  They  are  not  confined  to  one  part  of  the  course  of 
the  nerve,  but  affect  indifferently  sometimes  one,  sometimes  the  other  por- 
tion, and  are  frequently  situated  deeper  than  ordinary  sciatica,  involving 
not  only  the  muscles,  but  apparently  also  the  bones,  and  even  the  various 
joints.  They  are  often  accompanied  by  a  sensation  of  pressure  (cincture 
feeling)  around  the  ankles,  calves,  thighs,  or  lower  part  of  the  chest  or 
abdomen.  The  patient  may  experience  difficulty  in  voiding  the  urine,  or 
suffers  from  incontinence.  Another  symptom  of  considerable  value 
(though  it  is  very  frequently  absent)  is  irregularity  of  the  pupils.  The 
most  important  diagnostic  sign  of  ataxia  is  the  absence  of  the  patellar 
tendon  reflex,  which  is  almost  invariable  (T  found  it  present,  however,  in 
an  undoubted  case  of  ataxia  in  the  paralytic  stage).  The  patellar  reflex 
is  obtained  by  directing  the  patient  to  cross  one  knee  over  the  other,  and 
allow  the  pendent  leg  to  hang  loosely.  If  the  ligamentum  patellce,  which 
is  thus  placed  upon  the  stretch,  be  then  tapped  smartly  with  the  finger 
or  with  a  pleximeter,  a  sudden  forward  movement  of  the  entire  leg  will 
be  produced  in  healthy  individuals.'  In  ataxia  this  phenomenon  becomes 
lost,  even  before  any  ataxic  movements  are  visible  in  the  gait. 

Sciatica  is  sometimes,  though  rarely,  mistaken  for  hip-joint  disease 
and  vice  versa,  but  this  error  can  only  be  made  during  the  first  stage  of 
morbus  cox».  The  latter  disease  is  accompanied  by  drooping  and  partial 
effacement  of  the  gluteal  fold  on  the  affected  side,  the  limb  appears  to 
be  somewhat  shortened,  and  tenderness  is  manifested  when  the  joint  sur- 
faces are  brought  in  contact  with  one  another.  There  is  interference  with 
the  perfect  mobility  of  the  limb  at  the  hip-joint,  and  this  important  point 
is  determined  by  placing  the  patient  on  a  horizontal  even  surface,  the 
healthy  limb  being  also  on  the  level  surface,  and  the  diseased  limb  re- 
maining flexed;  it  will  then  be  found  that  the  pelvis  is  at  right  angles  to 
the  horizontal  limb,  and  that  the  lumbar  spine  is  in  contact  with  the  sur- 
face upon  which  the  patient  rests.  As  soon,  however,  as  an  attempt  is 
made  to  carry  the  flexed  limb  into  the  same  position  as  the  other,  the 
pelvis  Avill  be  found  to  tilt  upward,  carrying  the  lumbar  spine  along  with 
it,  so  that  the  hand  can  be  introduced  underneath  the  vertebrae.  These 
symptoms  are  always  present  in  hip-joint  disease,  and  a  careful  examina- 
tion will,  therefore,  enable  us  to  make  a  differential  diagnosis. 

Hysterical  joints  (Brodie's  joint)  are  sometimes  differentiated  with 
difficulty  from  sciatica  when  the  hip  is  involved.  This  affection  is  char- 
acterized by  extreme  tenderness  of  the  joint  to  slight  pressure,  while 
firm  compression  is  often  very  well  borne.  Painful  points  can  be  usu- 
ally detected  around  the  joint.  Contracture  of  the  hip  (which  disappears 
during  chloroform  narcosis)  is  a  common  feature,  and  may  lead  to  a  sus- 
picion of  inflammation  of  the  joint.  One  of  the  most  important  differen- 
tial diagnostic  points  is   the  fact   that   hysterical  joints,  unlike  sciatica, 

'  I  have  recently  noted  its  absence  in  two  of  my  students,  who  were  perfectly 
healthy. 


NEURALGIA.  159 

almost  invariably  appear  in  young  females  in  whom  other  well-marked 
symptoms  of  hysteria  are  also  present. 

An  important  feature  in  tlie  diagnosis  of  sciatica  is  the  localization  of 
the  primary  lesion.  It  is  impossible  for  us  to  enter  into  this  subject  in  ex- 
tenso,  and  we  can  only  refer  to  our  remarks  on  the  etiology  of  the  dis- 
ease. But  we  desire  especially  to  impress  the  necessity  of  a  careful  ex- 
ploration of  the  pelvis  (by  palpation,  vaginal  and  rectal  exploration), 
whenever  we  have  to  deal  with  an  obstinate  case  which  resists  ordinary 
methods  of  treatment.  Entirely  unlooked  for  and  veiy  valuable  data  will 
sometimes  be  revealed  from  a  compliance  with  this  rule.  In  every  case 
of  double  sciatica  we  should  not  alone  make  a  pelvic  exploration,  but  also 
carefully  examine  the  condition  of  the  vertebral  column. 


Treatment. 

The  exciting  cause  of  sciatica  can  sometimes  be  removed  by  a  resort 
to  surgical  measures,  such  as  the  extraction  of  foreign  bodies,  the  extri- 
cation of  the  nerve  from  constricting  cicatrices,  or  from  exuberant  callus 
formed  after  fracture  of  the  pelvis  or  long  bones  of  the  limb,  ligature  for 
aneurism  of  the  popliteal  artery,  etc.  When  the  affection  is  due  to  the 
pressure  of  intra-pelvic  exudations,  etc.,  great  relief  is  sometimes  afforded 
by  the  successive  application  of  fly-blisters  to  the  iliac  fossa  in  combina- 
tion with  palliative  doses  of  morphine  and  careful  attention  to  the  regu- 
lation of  the  bowels.  In  a  large  number  of  cases  we  are  powerless  to  re- 
move the  exciting  cause,  even  though  it  be  well  known,  and  we  are  then 
compelled  to  rely  exclusively  on  the  use  of  palliative  measures. 

In  ordinary  cases  of  sciatica  it  is  well  to  begin  treatment  with  the  ad- 
ministration of  a  saline  cathartic,  even  when  the  patient  states  that  the 
bowels  are  regular.  We  often  find  that  the  quantity  of  fgeces  voided  is 
insufHcient,  although  the  patient  goes  to  stool  every  day,  and  an  aloes 
pill,  taken  at  bedtime,  is  very  serviceable  under  such  circumstances.  The 
diet  should  be  carefully  regulated,  and  fatty  or  very  feculent  substances 
allowed  only  in  moderation.  The  patient  should  be  examined  with  regard 
to  the  presence  of  hemorrhoids,  and  appropriate  treatment  adopted. 
These  measures  are  especially  indicated  in  cases  in  which  the  patient  has 
recovered  from  one  attack  and  is  in  danger  of  a  relapse. 

When  the  pain  of  a  paroxysm  is  unendurable  the  hypodermic  admin- 
istration of  morphine  is  indicated  in  doses  adapted  to  each  individual 
case.  Many  authors  recommend  that  the  injections  be  made  over  the 
track  of  the  nerve,  or  even  into  its  tissue;  but  apart  from  the  fact  that 
an  injection  into  the  nerve  itself  is  an  operation  which  can  only  be  per- 
formed with  great  difficulty  with  an  ordinary  hypodermic  needle,  I  have 
been  unable  to  observe  any  special  beneficial  effects  from  local  injections. 

Dr.  Comegys  '  has  obtained  benefit  from  hypodermic  injections  of 
ether  during  the  attack,  and  regards  this  as  a  curative  measure. 

The  cui-ative  treatment  of  sciatica  consists  in  the  use  of  counter-irri- 
tants, the  administration  of  certain  nervines,  the  application  of  galvanism, 
and  surgical  interference. 

Fly-blisters  constitute  the  most  serviceable  form  of  counter-irritation. 
They  are  best  applied  over  the  painful  spots,  beginning  above  and  passing 
to  the  one  below  when  the  sore  caused  by  the  blister  previously  applied 

'  Cincin,  Lancet  and  Clinic,  1879,  it  10. 


160  FUNCTIONAL   NERVOUS    DISEASES. 

is  beginning  to  heal.  When  necessary,  a  considerable  portion  of  the 
upper  part  of  the  nerve  can  be  traversed  in  this  manner.  The  actual  cau- 
tery (if  we  include  this  among  counter-irritants)  is  the  least  painful  and 
most  convenient  form  at  our  command.  It  may  be  applied  either  across 
the  nerve  or  along  its  course,  and  should  be  employed  every  four  or  five 
days.  Although  not  productive  of  such  good  results  as  the  application 
of  the  fly-blister,  the  actual  cautery  often  proves  very  useful.  An  Italian 
author  has  reported  thirty-three  cases  of  cure  from  cautery  of  the  lobe  of 
the  ear.  The  electrical  wire  brush  or  counter-irritation  by  means  of  bi- 
sulphide of  carbon  may  also  be  resorted  to,  but  these  measures  are  of 
secondary  importance.  In  some  obstinate  cases  a  hypodermic  injection 
of  nitrate  of  silver  over  the  course  of  the  nerve  has  been  productive  of  ex- 
cellent results. 

Sulphate  of  strychnia  has  produced  better  effects  in  my  hands,  in  cases 
of  sciatica,  than  any  other  single  drug. 

In  the  beginning,  gr.  J^  — J^  may  be  administered  three  times  a  day, 
and  this  quantity  should  be  increased  by  one  dose  daily  until  the  physio- 
logical effects  of  the  drug  become  manifest.  It  should  then  be  continued 
in  somewhat  smaller  doses  for  a  period  of  two  or  three  weeks  before  be- 
ing abandoned;  if  the  patient  improves  under  its  use  it  may  be  adminis- 
tered for  a  much  longer  period.  This  remedy  proves  most  useful  in  idio- 
pathic cases  or  those  due  to  exposure,  etc.  It  is  impossible,  however,  to 
predict  whether  the  drug  will  be  of  service  or  not  in  any  individual  case. 
Some  patients  are  relieved  within  a  week  or  ten  days,  in  others  a  cure  is 
not  effected  within  several  weeks  or  a  month,  while  a  considerable  pro- 
portion are  unaffected  by  its  administration  or  grow  steadily  worse. 

Atropine  is  also  a  useful  remedy,  and,  like  strychnia,  must  be  admin- 
istered in  continually  increasing  doses  until  slight  toxic  effects  develop. 
As  in  the  case  of  strychnia,  we  cannot  determine  in  advance  whether  any 
advantage  will  be  obtained  from  its  employment,  and  we  will  often  find, 
in  severe  and  prolonged  cases  of  this  disease,  that  we  must  pass  blindly 
from  one  remedy  to  another,  in  the  hope  that  our  endeavors  will  finally 
prove  successful. 

Turpentine  has  been  employed  as  a  remedy  for  sciatica  for  more  than 
a  century,  and  at  one  time  was  held  in  very  high  favor.  It  may  be  given 
in  half-ounce  doses  (preferably  in  capsules),  and  should  be  taken  imme- 
diately after  meals.  I  have  failed  to  obtain  any  good  results  from  this 
drug. 

Of  late  I  have  made  some  use  of  aconitia  in  bad  cases  of  sciatica,  but 
the  employment  of  this  remedy  has  not  been  attended  with  very  brilliant 
results  in  my  hands.  It  has  sometimes  served  to  produce  decided  palli- 
ative effects,  but  has  not  caused  complete  relief. 

Galvanism  is  perhaps  the  most  generally  useful  remedy  at  our  com- 
mand in  the  treatment  of  sciatica.  I  have  employed  this  agent  exten- 
sively during  the  past  five  years,  and  have  become  more  and  more  con- 
vinced that  it  is  more  effective  than  any  other  single  remedy.  If  galvan- 
ism is  employed  in  the  expectation  that  every  case  will  succumb  to  its  in- 
fluence, we  will  be  sorely  disappointed,  but  I  have  found  that  a  consider- 
able proportion,  perhaps  a  half  of  all  the  cases,  undergo  marked  improve- 
ment or  complete  recovery.  In  exceptional  instances,  however,  the  pa- 
tients grow  steadily  worse  under  this  plan  of  treatment.  Dr.  V.  P. 
Gibney,  Surgeon  to  the  Hospital  for  Ruptured  and  Crippled,  who  has  had 
remarkable  success  in  the  treatment  of  sciatica  by  galvanism,  has  kindly 
furnished  me  with  the  manuscript  of  an  article  which  he  read  at  the  re- 


NEURALGIA.  161 

cent  meeting  of  the  American  Medical  Association,  and  I  cannot  do  bet- 
ter than  by  giving-  the  following  abstract  of  his  paper: 

"  Of  thirty-two  cases  of  sciatica  treated  by  the  strong  galvanic  cur- 
rent, twenty-four  were  relieved  of  pain  immediately  after  the  first  applica- 
tion, three  got  moderate  relief,  and  five  obtained  little  or  no  relief.  The 
immediate  relief  was  only  temporary,  the  paroxysms  returning,  as  a  rule, 
within  twelve  hours,  but  with  less  severity  and  persistency,  the  applica- 
tions being  repeated  daily  in  many  instances. 

"  Sixteen  cases  had  no  relapse,  and  can  with  safety  be  pronounced  per- 
manently cured,  four  obtained  no  permanent  relief,  and  seven  had  slight 
relapses  of  a  mild  character,  but  insufficient  to  keep  them  from  work. 

"  About  ten  sittings  was  found  to  be  the  average  number  necessary  to 
effect  a  cure,  the  current  varying  from  twenty  to  forty  Stoehrer's  cells  or 
their  equivalent.  In  applying  the  electricity  the  positive  pole  is  placed 
directly  over  the  exit  of  the  sciatic  nerve  from  the  sciatic  foramen.  The 
latter  spot  can  be  found  by  placing  the  thumb  of  the  hand  correspond- 
ing to  the  affected  limb  over  the  tip  of  the  trochanter  major,  and  the  mid- 
dle finger  over  the  tuber  ischii;  then  the  tip  of  the  index  finger  will  fall 
directly  over  the  great  sciatic  foramen.  If  firm  pressure  be  made  here, 
referred  sensations  will  be  felt  in  the  distribution  of  the  nerve.  The 
negative  pole  is  placed  in  the  popliteal  space,  or  wherever  there  is  most 
pain  or  numbness  in  the  course  of  the  nerve.  The  sittings  should  occupy 
ten  to  fifteen  minutes  every  day  or  twice  a  day  during  the  first  week. 
The  current  must  be  strong  enough  to  cause  severe  pain  and  even  vesica- 
tion." 

I  have  very  little  to  add  to  these  remarks,  which,  in  the  main,  accord 
entirely  with  my  own  experience.  In  my  practice,  however,  I  have  found 
that  the  position  of  the  poles  is  immaterial,  the  ascending  current  being 
as  efficacious  as  the  descending.  Nor  have  I  ever  found  it  necessary  to 
use  a  current  of  sufficient  intensity  to  produce  vesication. 

When  the  sciatica  is  present  in  a  very  severe  form  it  is  advisable  to 
employ  the  electricity  in  the  manner  recommended  for  neuritis  of  the 
sciatic,  the  nerve  being  galvanized  in  sections. 

As  a  rule,  to  which  there  are  very  few  exceptions,  galvanism  proves 
curative,  if  at  all,  within  a  few  weeks.  If  the  disease  has  not  undergone 
marked  improvement  within  a  fortnight,  it  will  be  useless  to  continue 
the  treatment  further. 

Surgical  measures  are  not  resorted  to  very  frequently  in  the  treatment 
of  sciatica.  Excision  of  the  nerve  is  never  admissible,  as  it  is  always  fol- 
lowed by  complete  paralysis  of  the  limb,  usually  attended  with  atrophy. 
This  operation  can  always  be  superseded  by  that  of  nerve-stretching, 
which  is  readily  performed  on  account  of  the  superficial  position  of  the 
nerve  and  its  large  size.  Nerve-stretching  appears  to  be  serviceable  even 
in  cases  in  which  the  neuralgia  is  due  to  an  inflammatory  process  in  the 
nerve. 

In  a  few  cases  the  surgeon  is  called  upon  to  remove  tumors  which 
press  upon  the  nerve,  to  excise  cicatrices,  etc.  These  operations  do  not 
always  prove  successful,  on  account  of  the  violence  to  which  the  nerve  is 
subjected,  and  the  subsequent  inflammatory  reaction  which  is  thus  de- 
veloped. 

11 


Peripheral  Paralysis. 


CHAPTER  I. 

CLINICAL  HISTORY. 

Paralysis  is  a  loss  of  muscular  power  due  to  an  interference  with  the 
transmission  of  nerve  force  from  its  site  of  development  in  the  central 
nervous  system  to  the  termination  of  the  nerve-fibres  in  the  muscles.  The 
term  paresis  simply  implies  a  partial  paralysis. 

Peripheral  paralysis  is  that  variety  in  which  the  interference  with  the 
transmission  of  nerve  force  is  due  to  some  lesion  which  is  operative  be- 
tween the  exit  of  the  nerves  from  the  nerve-centres,  and  their  termination 
in  the  muscular  fibres.  The  affection  may  develop  slowly  or  suddenly,  ac- 
cording to  the  nature  of  the  underlying  cause.  Thus,  a  sabre-cut  which 
entirely  divides  the  filaments  of  a  motor  nerve  must  produce  immediate 
paralysis  in  its  distribution.  The  gradual  compression  of  a  nerve,  how- 
ever, by  a  slowly  developing  neoplasm  in  its  neighborhood  will  produce 
paralysis  very  slowly,  and  the  gradually  developing  loss  of  power  may  be 
preceded  by  various  symptoms  of  irritation  on  the  part  of  the  nerve,  as 
we  shall  show  hereafter. 

All  parts  of  the  muscular  system  may  be  subjected  to  paralysis; 
changes  in  the  appearance  of  these  parts  are  due  to  the  fact  that  the  an- 
tagonist muscles  have  no  opposing  force  to  overcome,  and  therefore  exer- 
cise traction  upon  the  paralyzed  ones.  Thus,  in  paralysis  of  the  seventh 
nerve,  the  face  is  drawn  to  the  sound  side  because  the  healthy  muscles  no 
longer  meet  with  any  opposition  to  their  tonic  contraction. 

The  distribution  of  peripheral  paralysis  is  entirely  different,  in  the 
vast  majority  of  cases,  from  that  due  to  diseases  of  the  brain  or  spinal 
cord.  In  the  former  the  paralysis  is  situated,  as  the  very  term  implies, 
in  the  distribution  of  individual  nerves  or  of  a  number  of  nerves.  Thus, 
only  a  single  muscle  may  be  paralyzed,  as  for  instance  in  a  lesion  of  the 
posterior  thoracic  nerve  which  supplies  the  serratus  magnus  muscle.  When 
the  paralysis  is  due  to  some  affection  of  the  brain  or  spinal  cord,  however, 
the  muscles  affected  are  those  which  belong  together  functionally,  and,  as  a 
rule,  a  limb  is  paralyzed  as  a  whole.  Thus,  in  cerebral  affections,  the  par- 
alysis usually  assumes  the  hemiplegic,  and  in  disorders  of  the  spinal 
cord,  the  paraplegic  type.  There  are,  however,  numerous  exceptions  to 
this  rule;  not  infrequently  only  one  limb  is  paralyzed  as  the  result  of  cen- 
tral diseases,  and  in  very  rare  instances  only  a  few  muscles  are  involved. 
But  in  such  cases  there  are  usually  other  concomitant  symptoms  which 
indicate  the  site  of  the  lesion.      It  must  also  be  remembered  that  affections 


164  FUNCTIONAL    NERVOUS    DISEASES. 

of  the  peripheral  nerves  sometimes,  though  rarely,  give  rise  to  widespread 
paralyses.  Thus,  compression  of  the  cauda  equina  may  cause  paralysis 
of  the  lower  limbs.  In  one  case,  which  I  shall  report  in  full  at  a  later 
period,  the  hemiplegia  which  was  present  was  due,  in  my  opinion,  to  an 
afPection  of  the  peripheral  nerves.  Finally,  a  large  number  of  the  nerves 
of  the  body  may  be  subjected  at  the  same  time  to  some  lesion  capable  of 
producing  paralysis. 

Another  important  difference  between  peripheral  and  central  paralysis 
is  the  fact  that  the  affected  muscles  rarely  atrophy  to  any  appreciable  ex- 
tent in  the  latter.  Thus,  patients  suffering  from  cerebral  hemiplegia  may 
have  lost  entire  control  of  the  paralyzed  muscles  for  years,  yet  the  differ- 
ence in  the  circumference  of  the  healthy  and  paralyzed  limbs  will  be  so 
slight  that  it  can  scarcely  be  detected.  The  small  difference  which  does 
exist  is  undoubtedly  due  in  part  to  the  wasting  of  subcutaneous  adipose 
tissue  in  the  paralyzed  side.  In  peripheral  paralysis,  on  the  other  hand, 
muscular  wasting  always  occurs,  and  usually  with  considerable  rapidity. 
The  same  phenomenon  is  observed  in  a  few  diseases  of  the  medulla  oblon- 
gata and  spinal  cord,  which  are,  however,  recognizable  by  other  attendant 
symptoms,  to  which  we  shall  revert  at  length  in  the  section  on  diagnosis. 

Central  paralyses  are  less  frequently  attended  with  sensory  disturb- 
ances than  the  peripheral  forms.  This  is  especially  true  of  cerebral 
forms,  because  the  fibres  which  conduct  motion  and  sensation  are  situated 
at  a  greater  distance  from  one  another  in  the  brain  than  they  are  in  other 
parts  of  the  nervous  system.  In  the  peripheral  nerves  the  motor  and 
sensory  fibres  are  mingled  indiscriminately  with  one  another,  so  that  any 
noxious  influence  acting  upon  one  set  of  fibres  must  necessarily  affect  at 
the  same  time  the  other.  It  is  nevertheless  true  that,  as  an  almost  inva- 
riable rule,  the  sensory  fibres  are  less  involved  than  the  motor,  and,  when 
the  paralysis  is  not  well  marked,  it  is  not  infrequent  to  find  that  no  sens- 
ory disturbance  whatever  can  be  detected  in  the  distribution  of  the  af- 
fected nerve.  It  is  very  difficult  to  explain  this  peculiar  phenomenon, 
but  it  is  none  the  less  true  that  not  only  are  the  sensory  disturbances  less 
marked  than  the  motor,  but  that  the  former  also  disappear  more  rapidly 
than  the  latter.  Perhaps  the  sensory  fibres,  as  has  been  conjectured, 
represent  a  lower  grade  of  development  than  the  motor,  and  are  there- 
fore less  susceptible  to  external  influences. 

Unlike  central  paralysis,  the  peripheral  form  is  usually  attended  with 
vaso-motor  and  trophic  disturbances.  This  is  readily  understood  when 
we  remember  that  the  peripheral  nerves  contain  vaso-motor  and  trophic 
as  well  as  motor  and  sensory  fibres,  and  that  the  former  must  therefore 
be  implicated  to  a  certain  extent  in  any  affection  of  the  nerves.  These 
disorders  are  rarely  present  in  cerebral  diseases,  but  in  one  class  of  spinal 
affections  they  take  a  prominent  part,  which  will  form  the  subject  of  fur- 
ther comment  at  a  later  period. 

Finally,  the  reactions  of  the  affected  nerves  and  muscles  to  faradism 
and  galvanism  differ  markedly  in  peripheral  paralysis  from  those  observed 
in  the  vast  majority  of  central  nervous  affections,  as  we  show  shall  at 
length  in  the  course  of  this  section. 

Peripheral  paralysis  may  be  due  to  various  causes,  such  as  traumatism, 
inflammation,  rheumatic  influences,  etc.,  and  as  the  clinical  history  varies 
considerably  according  to  the  cause,  we  shall  enter  into  the  symptoma- 
tology of  each  of  these  varieties  in  detail. 


PERIPHERAL    PARALYSIS.  165 


Injuries  of  Neeves. 

We  shall  first  consider  that  form  of  paralysis  which  is  due  to  complete 
section  of  the  nerves,  the  history  of  which  has  been  very  thoroug-hly  in- 
vestigated by  means  of  physiological  experiments,  as  well  as  by  observa- 
tions upon  the  human  subject.  This  variety  is  produced  by  direct 
wounds  of  the  nerve,  such  as  arises  from  incised  wounds  with  a  knife,  sa- 
bre, piece  of  glass,  bullets,  etc. 

When  a  nerve  has  been  cut  across,  a  change  in  the  white  substance  of 
Schwann  first  becomes  evident.  Within  a  very  few  days  this  portion  co- 
agulates and  then  breaks  up  into  large,  irregular  masses  presenting  a 
double  contour.  These  masses  gradually  disintegrate  into  smaller  and 
smaller  fragments,  until  finally  nothing  remains  visible  but  an  accumula- 
tion of  fine  fat  globules  which  only  present  a  single  outline  (the  fat  gran- 
ules take  up  a  greater  space  than  the  original  medullary  substance,  and 
the  nerve-sheath  or  neurilemma  therefore  appears  swollen).  After  a 
few  weeks  these  products  of  degeneration  begin  to  be  absorbed,  and  fi- 
nally disappear  in  great  part.  The  axis  cylinder  does  not  change  so  rap- 
idly as  the  medullary  substance,  and  some  observers  even  maintain  that 
it  remains  entirely  unaffected.  The  weight  of  evidence,  however,  is  to 
the  effect  that  the  axis  cylinder  also  slowly  undergoes  a  similar  fatty  de- 
generation, and  is  finally  absorbed,  so  that  at  length  the  neurilemma  is 
almost  empty  or  encloses  a  small  amount  of  the  products  of  degeneration. 
The  neurilemma  also  undergoes  changes  ;  it  becomes  thickened,  its  nuclei 
increase  in  size  and  number,  and  numerous  white  globules  pass  between 
It  and  the  adjacent  ones.  The  latter  become  converted  into  spindle- 
shaped  cells,  and  finally  into  connective  tissue,  which  is  most  abundant 
in  the  neighborhood  of  the  sheath  of  the  nerve  ;  the  nerve,  therefore, 
undergoes  a  sclerotic  change. 

But  even  if  a  considerable  portion  of  the  nerve  is  excised,  the  cut 
ends  may  be  again  brought  into  union  with  one  another  by  means  of  new- 
formed  fibres.  The  manner  in  which  this  process  is  effected  is  still  in- 
volved in  obscurity.  We  know,  hoAvever,  from  clinical  experience,  that 
such  union  will  occur  despite  seemingly  impassable  obstacles,  so  that  it  is 
doubtful  whether  regeneration  will  not  occur  even  when  the  cut  ends  of 
the  nerves  have  been  carried  past  one  another,  and  thus  project  in  opposite 
directions.  This  fact  often  proves  a  great  obstacle  to  our  therapeutic 
measures,  as  in  cases  of  neuralgia  in  which,  after  excision  of  a  portion  of 
the  nerve,  we  are  anxious  to  avoid  reunion  of  the  cut  ends. 

The  muscles  supplied  by  the  divided  nerve  also  undergo  important 
changes.  The  muscular  fibrilte  diminish  considerably  in  size,  and  the 
transverse  striai  are  not  so  well  marked  as  in  the  normal  condition;  the 
fibres  present  a  cloudy  and  even  granular  appearance.  Increase  of  the  in- 
terstitial tissue  occurs  as  it  does  in  the  nerves;  a  large  number  of  white 
blood  globules  appear  between  the  muscular  fi.bres,  become  converted  into 
spindle  cells,  and  finally  into  fibrous  tissue.  When  these  changes  have 
not  attained  any  considerable  intensity  they  may  entirely  disappear,  and 
all  the  parts  involved  (the  nerves  and  muscles)  resume  their  former  nor- 
mal appearance. 

The  central  portion  of  the  nerve  may  also  undergo  anatomical  changes, 
though  these  are  not  constant.  They  consist  of  the  development  of 
neuromata  or  of  an  interstitial  neuritis,  which  is  usually  limited  to  a  small 
portion  of  the  nerve  immediately  adjacent  to  the  seat  of  injury.     In  some 


166  FUNCTIONAL    NERVOUS    DISEASES. 

cases,  as  we  shall  see  at  a  later  period,  the  neuritis  may  gradually  spread 
along  the  nerve  jt?er  coyxtinuitatem,  and  finally  involve  the  membranes  of 
the  spinal  cord,  or  the  spinal  cord  itself,  in  the  inflammatory  process. 
This,  however,  rarely  occurs  when  the  nerve  has  been  entirely  divided. 

In  those  cases  in  which  the  nerve  has  not  been  entirely  divided,  but 
has  undergone  slighter  grades  of  injury,  such  as  partial  division,  compres- 
sion or  contusion,  the  appearances  presented  by  the  organs  involved  are 
similar  to  those  described  above,  but  of  less  intensity. 

The  symptoms  produced  by  complete  section  of  a  nerve  depend  upon 
the  character  of  the  latter,  whether  motor,  sensory,  or  mixed.  In  all  cases 
the  trophic  and  vaso-motor  fibres  are  paralyzed  at  the  same  time  as  the  other 
fibres.  The  muscles  supplied  by  the  nerve  are  immediately  and  completely 
paralyzed,  and  remain  so  until  regeneration  has  occurred.  Sensation  is  not 
always  entirely  lost  in  the  parts  supplied  b}^  the  nerve.  Richet  mentions 
a  case  of  division  of  the  median  nerve  which  was  not  followed  by  the 
slightest  loss  of  sensation.  A  considerable  number  of  other  cases  have 
been  reported,  in  which  the  lost  sensation  reappeared  at  a  time  at  which 
regeneration  of  the  cut  nerve-fibres  (they  never  unite  by  first  intention) 
could  not  possibly  have  occurred.  Arloing  and  Tripier  have  explained 
these  cases  by  the  existence  of  recurrent  sensory  fibres,  which  sometimes 
pass  (especially  at  the  periphery)  from  the  trunk  of  one  nerve  to  that  of 
another. 

The  paralysis  of  the  vaso-motor  fibres  is  manifested  by  dilatation  of 
the  vessels  and  rise  of  temperature  in  the  parts  to  which  the  fibres  are 
distributed.  After  a  variable  period  the  temperature  of  the  parts  dimin- 
ishes, on  account  of  the  ensuing  atrophy  and  loss  of  mobility.  In 
complete  section  of  the  nerves,  the  paralysis  of  the  trophic  fibres  produces, 
as  a  rule,  simple  atrophy  of  the  muscular  tissue.  In  a  few  exceptional 
cases,  however,  other  trophic  changes  have  also  developed. 

When  the  division  of  the  nerve  has  been  incomplete,  or  when  the  in- 
jur}' is  due  to  compression,  contusion,  or  other  source  of  irritation,  the 
symptoms  vary  somewhat  from  those  described  above.  The  j^aralysis,  in 
such  instances,  is  not  so  complete,  its  distribution  and  severity  depending 
upon  the  extent  of  the  nerve  injury;  twitchings  and  contractures  of  the  af- 
fected muscles  may  also  be  present.  The  sensory  symptoms  are  also  more 
complex,  and  consist  of  anaesthesia  (which  may  not  be  diffused  over  the 
entire  distribution  of  the  affected  nerve,  but  is  sometimes  interspersed 
with  spots  of  hyperaesthesia);  shooting  pains  in  the  peripheral  distribution 
of  the  nerve,  which  sometimes  assume  a  neuralgic  character;  a  sensation 
of  numbness  and  tingling  in  the  parts.  The  trophic  sjnnptoms  may  be 
very  prominent,  and  are  similar  in  character  to  those  described  on  page  94. 
In  these  cases,  also,  the  symptoms  of  ascending  neuritis  are  sometimes 
mingled  with  those  due  to  the  injuiy  itself,  but  we  shall  defer  their  dis- 
cussion until  a  later  period.  In  order  to  give  a  clear  idea  of  the  multi- 
plicity of  the  symptoms  which  may  follow  nerve  injuries,  we  republish 
the  following  case  from  Weir  Mitchell's  treatise: 

Case  T. — "  'Wound  of  median  and  ulnar  nerves^'  atrophy  and  con- 
traction of  flexor  muscles;  atrophy  of  all  the  hand  muscles ;  neuro-trau- 
matic  arthritis;  loss  of  sensatioji;  moderate  ijnproveme?it:  discharge. 
G.  L.,  aged  thirty-one;  lumberman;  enlisted.  May,  1861,  Company  C,  1st 
Minnesota  Infantry.  He  was  healtliy  to  the  date  of  the  wound,  which 
was  received  July  3,  1803.  While  advancing  at  a  walk,  and  capping  liis 
gun,  a  ball  entered  the  right  biceps,  three  and  a  quarter  inches  above  the 


PERIPHERAL    PARALYSIS.  167 

level  of  the  internal  condyle,  and  made  its  exit  three  and  a  quarter  inches 
directly  below  the  same  condyle,  wounding  the  main  artery  and  the  ulnar 
and  median  nerves.  The  hand  and  forearm  flexed  spasmodically,  and  the 
man,  tying  a  handkerchief  around  the  arm  to  check  the  flow  of  blood, 
walked  to  the  rear,  suffering  with  some  pain  down  the  front  of  the  arm, 
but  not  in  the  hand.  Motion  and  feeling  were  both  absent.  Three  hours 
later  the  artery  was  tied.  A  cerate  dressing  was  applied,  and  no  splint 
was  at  any  time  used.  The  wound  healed  in  two  months,  and  at  this 
time  sensation  and  motion  began  to  improve.  He  was  admitted  to  Tur- 
ner's Lane  Hospital,  December  24, 1863,  when  his  case  was  thus  described: 
The  right  hand  is  congested  and  a  little  swollen.  In  the  flexor  carpi  radi- 
alis  the  loss  from  atrophy  is  one-half.  In  the  other  flexors,  supinators 
and  pronators  the  loss  is  one-third.  In  the  thumb  muscles  proper  and 
abductor  minimi  digiti  it  is  one-fourth. 

"  The  deep  and  superficial  flexoi-s  and  the  thumb  muscles  are  slightly 
contracted.  Up  to  the  third  month  the  fingers  were  straight,  but  about 
that  time  they  began  to  bend,  and  on  admission  were  semi-flexed. 

"  The  biceps  acts  very  little;  the  supinator  longus,  although  enfeebled, 
being  competent  to  flex  the  forearm.  Extension  is  incomplete  from  par- 
tial contraction  of  the  biceps,  owing  to  the  prolonged  flexion  of  the  arm; 
pronation  is  incomplete,  but  the  supinating  power  is  entire.  The  hand 
can  be  raised  only  to  the  arm  level,  when  the  contractions  of  muscles  and 
the  state  of  the  wrist-joint  check  it.  The  thumb  has  one-third  flexion  and 
extension,  owing  to  want  of  power. 

"The  first  joints  of  the  fingers  are  in  good  order;  the  second  a  little 
swollen  and  stiff;  the  third  joints  are  rigid,  enlarged  and  painful,  espe- 
cially in  the  index  finger.  The  first  joints  have  pretty  fair  mobility;  the 
second  but  little;  the  third  none  at  all.  As  the  fingers  are  semi-flexed, 
the  will  can  still  act  on  the  first  phalanges,  and  slightly  on  the  second, 
but  the  third  rest  bent  and  motionless.  The  same  statement  may  be 
made  as  to  the  power  to  voluntarily  extend  them.  The  contracted  state 
of  the  common  flexors  has  now  lessened,  but  the  joint  inflammations, 
which  arose  early  in  the  case,  have  fixed  the  fingers  in  the  vicious  posi- 
tions into  which  they  were  drawn  by  the  muscular  shortening. 

"Touch  is  good  in  the  arm;  absent  in  the  jDalm  and  palmar  face  of  the 
fingers,  except  as  to  the  thenar  eminence.  It  is  good  on  the  dorsum  of 
the  hand,  but  defective  on  the  back  of  the  last  phalanx  of  the  first  finger, 
the  second  and  third  phalanges  of  the  second  and  third  fingers,  and  on  the 
metacarpal  bone  of  the  fourth  finger. 

"Electro-muscular  contractility  is  lessened  in  the  supinator  longus; 
absent  in  the  common  flexors,  though  these  have  some  voluntary  power; 
nearly  absent  in  the  thumb  muscles,  the  muscles  of  the  fourth  finger,  and 
interosseal  groups. 

"  The  marked  feature  of  this  case  was  the  obstinate  and  painful  inflam- 
mation, and  stiffness  of  the  third  joints  of  the  fingers,  and  of  the  articu- 
lation of  the  wrist;  yet  these  conditions  were  nearly  entirely  relieved  by 
three  months  of  passive  motion,  electrization  by  induced  currents,  and  the 
dry  wire  brush,  douches,  and  attention  to  the  general  health." 

The  changes  in  the  electrical  reactions  of  the  affected  nerves  and 
muscles  are  extremely  interesting  and  important,  both  from  a  diagnostic 
and  prognostic  point  of  view. 

As  a  matter  of  course,  no  stimulation  of  the  nerve  above  the  site  of 
division  will  be  able  to  produce  a  response  in  the  muscles  to  which  the 


16S  FUNCTIONAL    NERVOUS    DISEASES. 

nerve  is  distributed.  The  reappearance  of  muscular  contractions  after 
such  stimulation  is  the  best  evidence  w^hich  we  possess  that  the  divided 
ends  of  the  nerve  have  become  united. 

Within  a  few  days  after  the  receipt  of  the  injury,  the  peripheral  por- 
tion of  the  nerve  begins  to  lose  its  excitability  to  both  the  faradic  and 
galvanic  currents,  and  this  keeps  on  steadily  increasing  until  finally  it  is 
altogether  lost,  i.  e.,  the  muscles  will  no  longer  respond  to  electrical  stim- 
ulation of  the  nerve  supplying  them.  Entire  abolition  usually  occurs 
within  a  period  of  about  two  weeks  (exceptionally,  the  excitability  of  the 
nerve  to  both  currents  is  slightly  increased  for  a  few  days  after  the 
injury,  but  after  this  time  it  always  pursues  the  course  described).  As 
recovery  occurs  the  irritability  of  the  nerve  to  both  currents  slowly 
reappears  and  increases  until  it  has  resumed  the  normal  proportions.  It 
is  a  curious  fact — and  one  which  I  have  noticed  on  frequent  occasions — 
that  even  after  the  paralysis  is  on  the  high  road  to  recovery  the  nerve 
will  not  respond  to  electrical  stimulus,  although  it  readily  allows  the 
transmission  of  the  impulse  of  the  will,  i.  e.,  the  patient  can  move  the 
muscles  voluntarily,  although  they  will  not  contract  upon  passing  an 
electrical  current  through  the  nerve. 

The  muscles  present  different  reactions  according  to  the  current 
employed.  Their  faradic  excitability  begins  to  diminish  in  two  or  three 
days,  and  then  steadily  decreases  until  it  is  entirely  abolished  within  two 
to  three  weeks.  In  those  cases  which  never  recover  it  remains  perma- 
nently absent  ;  in  those  which  are  susceptible  of  improvement  the  mus- 
culo-faradic  excitability  reappears  when  recovery  begins,  and  grows 
stronger  in  proportion  as  improvement  progresses.  The  galvanic  excita- 
bility of  the  muscles  pursues  an  entirely  different  course.  For  the  first 
week  or  ten  days  it  is  either  entirely  unaffected,  or  is  perhaps  slightly 
diminished.  But  at  this  time  the  galvanic  excitability  begins  to  grow 
stronger  and  increases  in  proportion  as  the  degeneration  of  the  muscles 
occurs,  until  finally  the  paralyzed  muscles  react  to  a  much  milder  current 
than  the  corresponding  ones  on  the  unaffected  side  of  the  body.'  The 
increase  in  the  galvano-muscular  excitability  is  sometimes  so  great  that  I 
have  frequently  observed  contraction  of  the  paralyzed  muscles  from  a 
current  of  two  cells,  whereas  the  healthy  muscles  would  only  respond  to 
ten  cells.  As  a  rule  the  character  of  the  muscular  contractions  is  some- 
what different  from  that  of  healthy  muscles — they  appear  at  a  longer 
period  after  the  passage  of  the  current,  and  continue  for  a  longer  time. 
This  change  in  the  muscular  excitability  is  known  as  the  degeneration- 
reaction  {entartungs-reacti07i  of  Erb).  If  no  improvement  occurs  in 
the  condition  of  the  muscles  the  galvanic  excitability  begins  to  diminish 
after  a  variable  period,  and  finally  becomes  entirely  extinct.  As  a  rule 
recovery  is  impossible  after  this  has  occurred,  but  some  exceptions  have 
been  reported,  and  two  such  have  come  under  my  notice.  When  im- 
provement does  take  place  the  increased  galvanic  excitability  gradually 
diminishes  until  finally  it  becomes  normal, 

'  There  are  also  other  more  complex  changes  in  the  reactions  of  the  muscles  to 
galvanism.  In  healthy  muscles  the  reaction  at  the  closure  of  the  negative  pole  is 
much  feebler  than  that  at  the  positive  ;  in  the  paralyzed  muscles  the  former  reaction 
increases  much  more  rapidly  than  the  latter,  so  that  it  finally  becomes  more  powerful. 
Furthermore,  the  reaction  at  the  opening  of  the  negative  pole  is  greater  than  that 
at  the  opening  of  the  positive  pole.  In  the  paralyzed  muscles  the  latter  increases 
much  more  rapidly  than  the  former,  and  finally  become  superior  to  it.  This  has  been 
termed  by  Brenner  "  reversal  of  the  formula." 


PERIPHERAL    PARALYSIS.  169 

The  remarks  just  made  only  hold  good  for  complete  division  of  the^ 
nerve  ;  when  the  injury  has  been  less  severe,  the  changes  in  the  electrical 
reactions  are  not  so  well  marked. 

In  the  mildest  forms  the  nerves  as  well  as  the  muscles  present 
entirely  normal  reactions  to  both  currents,  and  these  cases  always  recover 
very  rapidly.  There  are,  however,  numerous  intermediate  groups 
between  this  class  and  the  variety  described  above,  and  we  find  that  the 
electrical  reactions  vary  according  to  the  severity  of  the  nerve-wound. 
In  some  cases  there  is  simple  diminution  of  nerve  and  muscular  excita- 
bility to  both  currents,  a  certain  grade  of  irritability  being  preserved 
throughout  the  entire  course  of  the  affection.  In  others  the  musculo- 
faradic  excitability  is  lost,  while  the  musculo-galvanic  excitability, 
though  increased,  does  not  present  the  "  reversal  of  the  formula  "  to 
which  we  have  referred.  Numerous  other  variations  have  been  reported, 
but  it  is  unnecessary  to  enter  into  their  discussion  ;  they  are  merely 
the  result  of  variable  degrees  of  change  in  the  anatomical  condition  of 
the  affected  parts. 


Acute  Neuritis. 

The  consideration  of  peripheral  paralysis  from  inflammation  of  the 
nerve,  or  neuritis,  next  claims  our  attention.  Neuritis  includes  two 
varieties,  viz.,  the  acute  and  chronic. 

Acute  neuritis  is  usually  the  result  of  injury  of  the  nerve,  either  in 
gunshot  or  other  wounds  ;  idiopathic  cases  appear  to  be  exceedingly 
rare.  As  a  rule  the  inflammation  only  affects  the  injured  nerve  or 
nerves,  or,  in  idiopathic  cases,  is  limited  to  one  nerve,  or  perhaps  to  a 
plexus.  In  extremely  rare  instances,  however,  as  in  the  cases  recently 
reported  by  Eichhorst '  and  Leyden, "  a  very  large  number  of  nerves  situ- 
ated in  different  parts  of  the  body  are  simultaneously  involved. 

In  acute  neuritis  the  nerve  appears  swollen,  and  is  usually  of  a 
speckled  reddish  color;  small  punctate  hemorrhages  are  visible,  scattered 
here  and  there  throughout  the  sheath  and  tissue  of  the  nerve.  The 
capillaries  are  enlarged  and  are  surrounded  by  numerous  leucocytes 
which  have  also  escaped  between  the  nerve-fibres  ;  the  white  substance 
of  Schwann  has  usually  undergone  fatty  degeneration  and  has  been 
removed  in  places,  so  that  the  sheath  of  Schwann  collapses.  The  axis- 
cylinders  present  variable  appearances  ;  sometimes  they  are  in  a  con- 
dition of  simple  atrophy,  sometimes  cloudy  or  granular  ;  a  certain  num- 
ber disappear  entirely. 

The  disease  usually  begins  with  a  chill  and  considerable  fever  ; 
intense  pain  at  once  develops  along  the  course  of  the  affected  nerve, 
which  becomes  swollen  and  exquisitely  tender  to  the  touch,  so  that  the 
slightest  contact  produces  excruciating  agony  ;  in  some  cases  a  red  livid 
streak  is  visible  over  the  nerve,  at  other  times  the  intqgument  is  oedem- 
atous.  These  symptoms  may  be  combined,  in  the  beginning,  with 
delirium.  The  patient  suffers  continuously  from  pain  -m  loco  vxorhi,  and 
this  is  accompanied  at  times  by  sharp,  shooting  pains  in  the  distribution 
of  the  nerve  ;  paralysis  of  the  muscles  which  it  supplies  rapidly  super- 
venes.    The  skin  is  very  hypergesthetic,  but  this  condition  may  change 


1  Virch.  Arch.  Bd.  LXIX.  =  Charite-Annalen,  Berlin,  1880. 


170  FUNCTIOlSrAL    ITERVOUS    DISEASES. 

to  anaesthesia  after  a  few  days  ;  the  reflex  excitability  of  the  parts  is 
lost.  The  affected  limb  is  kept  motionless  on  account  of  the  pain,  and 
contracture  of  the  muscles  rapidly  occurs  in  some  cases.  After  a  variable 
period  the  inflammation  may  undergo  resolution,  and  the  symptoms  then 
subside,  or  it  may  pass  into  a  chronic  condition.  The  following  case, 
reported  by  Weir  Mitchell,  is  an  excellent  example  of  the  latter  variety: 

"J.  C,  sergeant,  consulted  me  on  account  of  loss  of  power  in  the 
arm,  with  severe  neuralgia.  At  Gettysburg  he  received  a  ball-wound  in 
the  left  neck,  splintering  the  clavicle  and  emerging  through  the  trape- 
zius. Some  fragments  of  bone  were  lifted  out  of  the  wound,  which  did 
well  until  a  week  later,  when,  on  the  way  to  Washington,  he  was  sud- 
denly taken  with  a  chill  of  some  severity,  followed  by  high  fever.  At 
the  same  time  the  whole  arm  began  to  ache,  darting  pains  shot  up  and 
down  it,  and  the  skin  on  the  inside  of  the  arm,  below  the  axilla,  was  seen 
to  be  red.  The  nerve  tracks  were  extremely  tender.  On  the  third  day 
the  whole  arm  was  somewhat  swollen,  and  the  darting  and  aching  pain 
was  only  subdued  by  frequent  hypodermic  injections.  His  first  notable  re- 
lief was  obtained  by  an  application  of  cut-cups  to  the  neck  and  shoulder, 
and  gradually  the  pain  lessened  to  its  present  grade  of  severity.  The 
ulnar  and  median  were  hard,  enormously  enlarged,  and  very  tender.  J. 
C.  described  himself  as  having  been  made  delirious  by  the  earlier  pain 
of  his  disease;  and  even  when  seen  by  me  after  it  had  been  abated,  he 
showed  very  plainly  that  the  mind  as  well  as  the  body  had  suffered — his 
memory  being  impaired,  and  his  temper  excessively  irritable." 

As  we  have  stated  above,  two  very  interesting  cases  have  been  re- 
ported in  which  the  neuritis  involved  a  large  number  of  nerves  in  various 
parts  of  the  body.  The  following  is  an  abstract  of  Eichhorst's  case  which 
he  described  under  the  term  acute  progressive  neuritis: 

"  A  woman,  who  was  apparently  suffering  from  quotidian  intermittent 
fever,  was  suddenly  paralyzed  in  the  left  peroneal  nerve,  which  lost 
faradic  excitability  within  twenty-four  hours.  The  other  peripheral 
nerves  gradually  became  paralyzed,  so  that  all  the  limbs  were  paralyzed 
in  ten  days.     Amblyopia  then  developed  and  finally  death. 

"Upon  the  autopsy  no  change  was  found  in  the  brain  or  cord;  the 
peripheral  nerves,  however,  were  all  of  a  dirty  grayish  red  color.  The 
perineurium  was  very  rich  in  vessels,  which  were  surrounded  by  lymph- 
oid cells;  the  blood-vessels  were  thickened  in  places.  The  nerve-fibres 
were  only  degenerated  in   the  neighborhood  of  the  perineurium." 

Leyden's  case,  which  has  been  referred  to  above,  is  somewhat  simi- 
lar to  this  in  its  general  outlines;  it  also  began  suddenly  with  acute 
symptoms,  but  the  neuritis  afterward  passed  into  a  chronic  stage.  The 
patient  died  a  year  later  from  urasmia,  the  result  of  small  contracted 
kidneys. 

As  we  shall  see  further  on,  these  exceptional  cases  bear  very  interest- 
in  grelations  to  the  pathology  of  certain  diseases  of  the  spinal  cord. 


Chronic  Neuritis. 

Chronic  neuritis  is  sometimes  an  outcome  of  the  acute  form  of  the 
■disease.  It  is  also  due  to  direct  injury  of  the  nerves,  to  compression  in 
consequence  of  various  lesions  in  their  vicinity,  such  as  the  pressure  of 
tumors,  excessive  callus,  etc.,  the  spread  of  inflammation  from  adjacent 
parts,  exposure,  etc.     An  attempt  has  been  made  to  divide  the  affection 


PERIPHERAL    PARALYSIS.  I7l 

into  two  forms,  viz.,  perineuritis  or  inflammation  of  the  sheath  of  the 
nerve,  and  neuritis  proper  or  inflammation  of  the  nerve  itself.  Such  a 
distinction  is  impracticable,  however,  from  a  clinical  point  of  view,  and 
very  often  from  an  anatomo-pathological  standpoint,  since  both  these 
lesions  are  often  combined. 

When  the  inflammation  is  more  interstitial  in  character  the  sheath  of 
the  nerve  and  the  interstitial  connective  tissue  are  thickened  from  an  in- 
crease of  spindle  cells  and  new  formed  fibrous  tissue;  in  consequence  of 
this  sclerotic  change  the  nerve-fibres  are  pressed  upon  and  undergo 
atrophy;  adipose  cells  sometimes  develop  between  the  fibres.  In  paren- 
chymatous neuritis  the  nerve-fibres  undergo  the  most  prominent  change. 
The  axis  cylinders  are  frequently  increased  in  size,  though  sometimes 
they  are  atrophied;  the  white  substance  of  Schwann  has  degenerated  in 
some  places  and  disappeared  in  others,  allowing  the  sheath  to  collapse. 
The  blood-vessels  are  thickened,  and  may^  be  surrounded  by  capillary  ex- 
travasations of  blood. 

The  muscles  supplied  by  the  affected  nerve  present  th,e  same  changes 
as  those  described  on  page  1G5,  after  division  of  a  nerve. 

The  symptomatology  varies  considerabl}^,  according  to  the  intensity  of 
the  inflammatory  process.  The  disease  usually  begins  by  a  feeling  of 
numbness  and  weakness  in  the  distribution  of  the  nerve  involved.  After 
a  longer  or  shorter  period  the  patient  begins  to  suffer  from  pain.  In 
the  beginning  this  consists  of  mere  soreness  along  the  course  of  the  nerve, 
which  soon  grows  more  severe,  until  finally  an  intense  steady  pain  is  felt. 
In  some  cases  paroxysms  of  shooting  pain  are  experienced  at  longer  or 
shorter  intervals;  their  character  is  very  similar  to  that  of  attacks  of 
neuralgia,  but  the  former  present  a  greater  tendency  to  propagation  in 
a  centripetal  as  well  as  a  centrifugal  direction.  The  nerve  is  always  ten- 
der on  pressure  (when  accessible  to  the  touch),  but  no  circumscribed  pain- 
ful spots  are  observed,  such  as  we  find  in  true  neuralgia.  When  the 
nerve  is  situated  directly  underneath  the  skin  it  is  often  found  to  be  en- 
larged. Mistakes  are  readily  made,  however,  in  this  respect,  and  we 
should  therefore  always  compare  the  inflamed  nerve  with  the  corresponding 
one  on  the  opposite  side  of  the  body.  When  the  inflammatory  process  is 
a  severe  one  the  integument  supplied  by  the  affected  nerve  is  profound- 
ly anJESthetic;  in  less  marked  cases  spots  of  superficial  anaesthesia  may 
alternate  with  patches  of  hypersesthesia.  The  patients  also  complain  of 
sensations  of  numbness  and  tingling  or  a  feeling  of  formication.  The 
muscles  undergo  a  greater  or  less  amount  of  atrophy,  according  to  the 
degree  of  implicatron  of  the  nerve-fibres.  Fibrillary  twitchings  and 
spasms  are  often  noticeable  in  the  paralyzed  and  paretic  muscles;  contrac- 
ture of  these  muscles  may  also  take  place. 

The  electrical  reactions  present  marked  variations.  Thus  the  affected 
nerve,  in  slight  cases,  may  be  more  excitable  to  both  the  faradic  and  gal- 
vanic currents  than  in  the  normal  condition.  As  the  nerve-changes 
grow  more  intense,  the  excitability  to  both  currents  diminishes,  and 
finally  disappears  altogether.  Similar  variations  are  noticeable  in  the 
electrical  muscular  reacrions.  Those  muscles  which  have  undergone  pro- 
found atrophy  always  present  the  degeneration  reaction  (vide  p.  168), 
while  those  least  affected  may  react  normally  to  both  currents.  Erb's 
so-called  "  middle  forms  "  of  degeneration  reaction  may  also  be  present. 
It  is  not  at  all  infrequent,  especially  when  several  nerves  are  involved,  to 
find  all  these  different  varieties  of  electro-muscular  reactions  in  one 
individual. 


172  FUNCTIONAL    NERVOUS    DISEASES. 

The  trophic  changes  are  sometimes  very  manifold;  and  the  skin,  hair, 
nails,  joints,  muscles,  and  bones,  may  all  be  involved  in  these  changes. 
They  are  identical  in  character  vv^ith  those  noticed  in  severe  cases  of  neu- 
ralgia, to  which  we  have  previously  referred.  It  will  therefore  be  un- 
necessary to  dilate  upon  them  at  this  time. 

The  following  case,  which  I  published  in  the  3fedical  Record,  April 
26, 1879,  is  a  good  example  of  chronic  neuritis,  and  also  illustrates  the  ten- 
dency to  the  propagation  of  the  inflammation  of  which  we  have  spoken. 

Case  I. — The  patient's  name  is  Wm.  W.,  get.  35  years;  family  his- 
tory unimportant;  married,  and  has  healthy  children;  he  has  never  had 
syphilis  or  other  venereal  disease;  his  habits  have  always  been  good. 
The  patient  was  in  robust  health  until  the  war  of  the  rebellion,  when  he 
enlisted  as  a  soldier,  and  contracted  dysentery  during  his  term  of  service. 

He  first  came  under  my  notice  at  the   Class  for  Nervous  Diseases  of 
the  Bellevue  Out-Door  Department,  on  December  13, 1877.     The  patient 
was  anemic  and  somewhat  emaciated;  he  complained  of  slight  cough  and 
expectoration  in  the  morning;  physical  exploration  of  the  chest  was  not 
made  at  that  time.     A  year   ago   the  patient  received  an  injury  to  the 
right  elbow,  resulting  in  the  formation  of  a  boil  over  the  olecranon  pro- 
cess;   this  healed   kindly  in  two   or  three  weeks,  leaving  no   apparent 
traces.     About  five   weeks   ago  he  again  suffered  from  a  boil,  situated 
in  the  same   locality  as  the  previous  one,  and  coming  on  without  any 
apparent  provocation.     The  swelling  occupied  the  entire  posterior  part 
of    the    elbow.     A    month    later    (nearly    two    weeks    ago),    and  before 
the  boil  had  healed,  the  patient  noticed  a  feeling  of  numbness  and  anaes- 
thesia appearing   on  the  anterior  and  posterior  surfaces  of  the  forearm. 
This  gradually  spread  downward,  involving  the  anterior  and  posterior  as- 
pects of  the  little  finger  and   the  ulnar  border  of  the   ring  finger;  these 
fingers  became  paretic,  pari  passu  with  the   anaesthesia.     The  anaesthe- 
tic integument  soon  began  to  grow  dusky  red,  became  somewhat  thick- 
ened, and   small,  whitish   scales   developed  over  its  surface.     Slight  pain 
and  tenderness  now  appeared  in  the  fold  of  the   elbow  and  along  the 
course  of  the  ulnar  nerve  in  the  forearm.     Soon   after  the   patient  came 
under  my  care  the  tenderness  spread  upward  in  the  arm,  along  the  course 
of  the  ulnar  nerve  into  the  axillary  region,  and  was  even   present   along 
the  course  of  the  brachial  plexus  in  the  neck.     He  was  treated  by  hot 
douches,  actual  cautery  along  the   affected  nerves,  and   the   descending 
constant  current,  as  topical  remedies;    the  internal  medication  consist- 
ed of  iodide  of  potassium,  fifteen  grains  three  times  a  day,  and  thirty 
drops  of  the  fluid  extract  of  ergot  three  times  a  day.     In  the  course  of 
two  weeks  the  pain  and  tenderness  along  the  nerve-trunks  had  almost 
entirely  disappeared;  the  skin  of  the  affected  region  was  still  insensible 
to  the  prick  of  a  pin,  but    a  less  intense  faradic   current   than   formerly 
was  appreciated.     The  interosseous  muscles  are  now  becoming  paretic; 
the  flexors  of  the  little  and  ring  fingers  are  apparently  somewhat  stronger 
than  formerly.     Treatment  was  now  restricted  to  the  use  of  galvanism 
and  the  iodide  of  potassium.     The  patient  remained  in  statu  quo  until 
February    10,   1878,  when   the  following  notes  were  taken:  general  ap- 
pearance poor;   heart-sounds  normal;    signs  of  incipient  phthisis  at  the 
apex  of   the    right  lung;  good   deal    of  cough   and    expectoration;    pa- 
tient   suffers    from    profuse    night-sweats.       Upon    examination    of   the 
right  arm   attention  is  attracted  by  the  dusky  redness  of  the  skin  in  re- 
gions which  accurately  represent  the  distribution  of  the  internal  and  ex- 


PERIPHERAL    PARALYSIS.  173 

ternal  cutaneous  nerves  and  the  cutaneous  branch  of  tlie  musculo-spiral. 
He  is  unable  to  feel  the  prick  of  a  pin  in  this  region  even  when  it  draws 
blood;  he  does  not  feel  a  constant  current  of  thirty-two  Stoehrer's  cells; 
feels  quite  readily  a  secondary  faradic  current  of  moderate  intensity. 
No  tenderness  on  pressure  along  any  of  the  nerve-trunks;  the  right 
hand  forces  the  dynamometer  to  46,  the  left  hand  to  180°.  On  inspec- 
tion it  is  found  that  the  adductor  pollicis  can  barely  adduct  the  thumb, 
and  the  dorsal  interossei  are  considerably  atrophied.  On  asking  the  pa- 
tient to  move  his  fingers,  it  is  evident  that  the  palmar  interossei  and  the 
three  inner  lumbricales  do  not  act  as  vigorously  as  in  the  left  hand,  and 
it  is  reasonable  to  suppose  that  they  are  also  atrophied.  The  motor 
nerve  affected  in  the  arm  is  therefore  the  ulnar.  The  paralyzed  muscles 
did  not  respond  to  the  faradic  current.  In  the  arm  the  ulnar  nerve  can 
be  traced  from  the  groove  between  the  internal  condyle  and  the  olecra- 
non process  upward  into  the  axilla  as  a  thick,  indurated  cord,  which  is  not, 
however,  sensitive  to  pressure  at  the  present  time;  the  tenderness  along 
the  brachial  plexus  has  also  disappeared.  A  red  patch  is  visible  on  the 
side  of  the  neck  and  the  tip  of  the  ear  (right  side).  This  region,  corre- 
sponding to  the  auricularis  magnus  nerve,  feels  numb,  and  on  testino-  it 
with  the  festhesiometer,  it  is  evidently  markedly  anesthetic.  The  two 
points  of  the  a^sthesiometer  are  only  distinguished  apart  at  thirty  mm., 
but  on  the  corresponding  portion  of  the  left  side  at  fifteen  mm.  Imme- 
diately below  the  inferior  angle  of  the  right  scapula  is  a  spot  nearly  as 
large  as  a  silver  dollar,  at  which  the  skin  presents  the  same  appearances 
as  in  the  neck  and  arm;  this  region  is  also  anaesthetic,  and  two  points  can- 
not be  distinguished  apart  over  this  spot.  To-day  the  patient  informs 
me,  for  the  first  time,  of  his  dysenteric  affection.  Ordered  subnitrate  of 
bismuth,  gr.  xxx.,  t.i.d.,  which,  in  a  few  days,  reduced  the  number  of 
passages  to  two  or  three  per  diem,  and  rendered  them  healthy  in  appear- 
ance; atropia  was  ordered  for  the  night-sweats  with  excellent  results. 
The  iodide  of  potassium  was  continued  in  the  same  doses  as  before,  and 
the  constant  descending  current  was  passed  down  the  cervical  spine,  and 
along  the  course  of  the  brachial  plexus  and  of  the  nerves  of  the  arm  and 
forearm,  every  other  day. 

April  2,  1878. — General  health  greatly  improved;  coughs  very  little; 
no  night-sweats;  has  one  or  two  healthy  passages  from  the  bowels  daily. 
The  patient  is  now  able  to  adduct  the  thumb  to  the  base  of  the  ring  fin- 
ger, and  can  abduct  and  adduct  all  the  fingers  except  the  ring  finger. 
The  eruption  on  the  forearm  has  faded  a  great  deal,  especially  toward  its 
centre.  Sensation  has  improved  very  little;  pain  is  absent,  except  in  the 
little  finger  and  the  ulnar  side  of  the  ring  finger  (hot,  smarting  pain). 
The  anfesthesia  of  the  reddened  patch  on  the  side  of  the  neck  is,  perhaps, 
a  little  less  marked  than  at  the  date  of  the  last  note,  and  the  eruption  is 
somewhat  paler.  The  patient  informs  me  that  he  has  noticed,  since  the 
beginning  of  the  week,  a  numb,  red  spot  on  the  middle  of  the  thigh  an- 
teriorly, and  about  six  inches  below  Poupart's  ligament.  This  patch  of 
eruption,  which  is  as  large  as  a  silver  dollar,  and  paler  in  the  centre  than 
at  the  periphery,  is  markedly  anresthetic;  a  similar  spot,  as  large  as  a 
dime,  is  found  over  the  left  deltoid  muscle.  He  continued  to  improve 
very  slowly  until  the  winter  of  1878,  when  he  returned  to  work  as  a  night- 
watchman,  and  passed  out  of  my  observation. 

This  case  has  important  bearings  upon  the  question  of  neuritis  ascen- 
dens  and  neuritis  migrans.     During  the   last   twenty-five  years  there  has 


174  FUNCTIONAL    NERVOUS    DISEASES. 

been  a  strong  tendency  among  neurologists  to  entirely  discard  the  old 
doctrine  of  reflex  paralysis,  but  there  is  no  doubt  that  in  a  few  cases  the 
theory  of  reflex  inhibitory  action  is  alone  sufficient  to  account  for  the 
paralysis  produced.  Thus  Landry  reports  a  case  of  paralysis,  associated 
with  anteversion  of  the  uterus,  which  disappeared  immediately  after  the 
organ  was  replaced  in  its  normal  position.  M.  Rosenthal  observed  the  dis- 
appearance of  a  suddenly-developed  paraparesis  after  the  extraction  of  a 
needle  which  had  been  introduced  into  the  vagina.  Madge  reports  a  case 
of  paralysis  developing  during  pregnancy,  which  disappeared  after  the  de- 
livery of  a  dead  four  months  fcetus.  Fuller  '  mentions  the  case  of  a  boy, 
cet.  3  years-  suffering  from  paralysis  of  the  right  arm  and  of  both  legs, 
which  was  relieved  by  the  expulsion  of  fifty-three  lumbricoid  worms. 
The  theory  of  reflex  inhibition  must  also  be  invoked  to  explain  those 
cases  (of  which  Mitchell  has  reported  several),  in  which  an  injury  to  one 
nerve  has  produced  paralysis  in  the  distribution  of  another,  and  in  such 
a  short  period  of  time  that  no  anatomical  lesion  could  have  been  pro- 
duced. 

But  this  theory  will  evidently  not  suffice  for  all  cases  of  this  nature. 
In  many  instances  post-mortem  examination  revealed  the  presence  of  in- 
flammatory processes  in  the  spinal  cord  or  its  meninges,  in  cases  which 
had  been  regarded  during  life  as  examples  of  reflex  paralysis  from  blad- 
der or  uterine  disease,  etc.  The  histories  of  the  older  cases  of  this  char- 
acter are  deficient  in  microscopical  examination  of  the  medullary  tissue, 
and  must  therefore  be  discarded.  In  order  to  explain  the  cases  included 
in  this  category  in  which  anatomical  lesions  were  found  in  the  spinal  cord, 
resort  was  had  to  the  theory  of  neuritis  migrans,  and  this  doctrine  has 
been  favorably  entertained  by  the  majority  of  living  pathologists.  In 
addition  to  the  clinical  aspects  of  the  question,  physiological  experiments 
were  also  adduced  to  substantiate  it.  Thus,  Tiesler,  Klemm,  Feinberg, 
and  Niedick  made  numerous  experiments  upon  animals  by  producing  ir- 
ritation of  the  sciatic  nerve  in  some  portion  of  its  course,  either  by  inject- 
ing a  foreign  matter  into  its  substance,  or  by  cauterizing  it  with  nitrate 
of  silver  or  caustic  potassa.  With  the  exception  of  Feinberg,  these  ob- 
servers announced  as  the  results  of  their  investigations  that  the  irrita- 
tion of  the  nerve  in  the  manner  referred  to  produces  neuritis  at  the  irri- 
tated spot,  and  that,  furthermore,  evidences  of  inflammation  appear  in 
the  course  of  the  nerves,  although  the  nerve-tissue  may  be  perfectly 
healthy  between  two  inflammatory  foci.  In  addition,  scattered  foyers  of 
myelitis  were  found  disseminated  throughout  the  cord.  None  of  these 
experimenters,  however,  resorted  to  microscopical  examination  of  the  tis- 
sues, nor  did  they  compare  the  appearances  presented  with  those  found 
in  healthy  animals.  Feinberg  found,  as  the  result  of  his  investigations, 
that  neuritis  was  produced  at  that  portion  of  the  nerve  which  had  been 
irritated,  but  that  the  more  central  parts  of  the  nerve  were  intact.  He 
nevertheless  obtained  evidences  of  myelitis  in  the  cord.  This  observer 
is  inclined  to  regard  the  myelitic  process  as  due  to  reflex  irritation  of 
vasomotor  nerves  (contraction  and  secondary  dilatation  of  the  medullary 
vessels). 

In  December,  1877,  Ottomar  Rosenbach  published  an  article  in  Kleb's 
"  Archiv.  f.  exp.  Path.  u.  Pharmak.,"  in  which  he  arrived  at  entirely- 
opposite  results  from  those  of  the  observers  previously  mentioned.  Dr. 
Rosenbach  made  a  series  of  very  careful  experiments  upon  the  pneumo- 

'  The  Lancet,  December,  1865. 


PERIPHERAL    PARALYSIS.  175 

gastric  and  sciatic  nerves  in  rabbits,  and,  although  he  could  develop  a 
perineuritis  at  the  irritated  point,  in  not  a  single  instance  was  he  able  to 
discover  any  evidences  of  neuritis  migrans  or  of  secondary  myelitis. 
All  his  experiments  were  accompanied  by  careful  microscopical  examina- 
tions— a  precaution  which  had  been  omitted  in  the  above-mentioned  re- 
searches. Rosenbach  also  calls  attention  to  the  fact  that  no  controlling 
observations  were  made  upon  healthy  animals  by  either  Klemm,Tiesler, 
Feinberg  or  Niedick,  and  that  many  of  the  appearances  which  the  latter 
regarded  as  pathological  were,  in  fact,  perfectly  normal. 

Similar  experiments  have  been  made  more  recently  by  H.  Treub  '  and 
have  entirely  substantiated  the  conclusions  arrived  at  by  Kosenbach. 

Whether  or  not  the  experiments  of  Rosenbach  and  Treub  dispi-ove 
the  possibility  of  the  production  of  neuritis  migrans,  we  shall  not  discuss 
now.  We  are,  however,  warranted  in  the  assertion  that  its  existence  has 
not  been  experimentally  established,  and  that  other  and  more  careful  ex- 
periments are  necessary  to  settle  this  vexed  question. 

We  must  therefore  rely  for  a  solution  of  the  problem  upon  patholo- 
gical and  clinical  data. 

Leyden  *  reports  two  cases  in  both  of  which  the  paralyses  were  secon- 
dary to  disease  of  the  bladder,  and  in  which  the  autopsy  showed  the  ex- 
istence of  widespread  myelitic  softening.  The  myelitis  started  from  that 
part  of  the  cord  in  which  the  nerves  supplying  the  bladder  originate,  and 
we  are  therefore  naturally  led  to  suppose  that  the  inflammatory  process 
passed  upward  from  the  bladder,  and  along  the  nerves,  until  it  reached 
the  cord.  But  Leyden  himself  remarks  that  there  is  no  positive  proof  in 
support  of  this  hypothesis.  T  have  been  unable  to  discover  any  other 
analogous  cases  of  equal  importance  after  a  survey  of  the  medical  litera- 
ture which  has  appeared  since  the  publication  of  Leyden's  work. 

The  case  of  Wm.  W.,  which  I  have  reported  above,  appears  to  me  to 
fill  an  hiatus  in  this  direction.  The  primary  affection  was  evidently  a 
neuritis  of  the  internal  cutaneous,  external  cutaneous,  and  ulnar  nerves, 
caused  by  an  extension  of  inflammation  from  the  boil  situated  on  the 
elbow.  The  fact  that  the  boil  was  primarily  seated  over  the  olecranon 
process,  and  from  thence  spread  internally  and  externally,  is  a  sufficient 
anatomical  explanation  of  the  fact  that  the  three  nerves  in  question  were 
implicated  to  the  exclusion  of  the  other  nerves  situated  in  the  fold  of  the 
elbow.  At  a  later  period  pain  and  tenderness  became  evident  along  the 
course  of  the  ulnar  nerve  in  the  arm,  and  the  nerve  could  be  traced  as  a 
thickened,  indurated  cord  from  the  back  of  the  inner  condyle,  along  the 
inner  side  of  the  arm  into  the  axillary  space.  These  phenomena  undoubt- 
edly indicated  extension  of  the  inflammation  along  the  ulnar  nerve.  At 
a  still  later  period  tenderness  became  evident  along  the  course  of  the 
brachial  plexus  in  the  neck,  indicating  the  further  extension  of  the  neu- 
ritis along  the  nerve-trunk. 

The  next  nerve  to  become  involved  was  the  auricularis  magnus,  as 
was  evidenced  by  the  appearance  of  anaesthesia  and  of  the  trophic  erup- 
tion referred  to  previously,  in  its  distribution  to  the  lobe  of  the  ear  and 
to  the  side  of  the  neck.  Now  the  ulnar  nerve  which  had  been  previously 
implicated  arises  from  the  eighth  cervical  and  first  dorsal  nerves,  while 
the  auricularis  magnus  is  given  off  from  the  second  or  third  cervical  nerves. 
If  we  acknowledge  that  the  implication  of  the  auricularis  magnus  was  sec- 

'  Arch   f.  exp.  Path.  n.  Pharm.,  p.  398,  1879. 
■  Klinik  f.  Ilueckenmarkskrankheiten. 


176  FUNCTIONAL    NERVOUS    DISEASES. 

■ondary  to  that  of  the  ulnar  nerve  (and  no  other  explanation  is  open  to 
us),  we  are  forced  to  conclude  that  the  affection  of  the  former  was  caused 
by  some  inflammatory  process  within  the  spinal  canal.  This  idea  is  still 
further  strengthened  by  the  subsequent  appearance  of  similar  spots  of 
auEesthesiaand  of  the  trophic  eruption  in  other  portions  of  the  body  (deltoid 
muscle,  scapula,  thigh).  What  the  nature  of  the  medullary  lesion  was 
we  are  unable  to  state.  It  may  have  been  a  disseminated  chronic  myelitis, 
or  the  inflammation  may  have  been  limited  to  the  meninges.  The  spinal 
symptoms  were  so  slight  that  it  would  be  rash  to  venture  a  differential 
diagnosis  between  these  two  conditions. 

It  appears  to  me  that  this  case  demonstrates  from  a  clinical  stand- 
point (and  with  almost  as  much  positiveness  as  a  successful  physiological 
experiment)  that  ascending  neuritis  is  capable  of  developing  secondary 
inflammatory  changes  in  the  cord,  by  means  of  a  simple  extension  of  the 
neuritic  process  per  contimdtatem. 

This  tendency  to  the  upward  spread  of  the  chronic  inflammatory  pro- 
■cess  along  the  nerve  which  was  primarily  affected,  is  quite  commonly  met 
with  in  cases  which  belong  to  the  category  at  present  under  discussion. 
As  a  rule,  however,  the  spread  of  the  inflammation  stops  at  the  nerve 
plexuses,  and  does  not  continue  as  far  as  the  spinal  cord. 

There  is  also  strong  reason  to  believe  that  neuritis  may  be  propagated 
downward  along  the  course  of  the  nerve,  as  appears  to  have  been  the 
case  in  the  following  example  :  A  patient  fell  upon  the  left  shoulder,  and 
this  injury  was  followed  by  symptoms  of  neuritis  in  the  circumflex  nerv^e. 
"Within  a  month  pain  and  tenderness  were  felt  in  the  brachial  plexus,  with 
shooting  pains  along  the  circumflex  nerve  and  very  marked  atrophy  of 
the  deltoid  muscle.  This  was  followed  by  the  development  of  pain  and 
tenderness  along  the  nerve-trunks  in  the  arm,  and  shooting  pains  along 
the  distribution  of  the  ulnar  nerve  in  the  forearm. 

The  development  of  pain  and  tenderness  in  the  nerves  of  the  arm 
subsequently  to  the  appearance  of  these  symptoms  in  the  course  of  the 
brachial  plexus  probably  indicated  a  downward  spread  of  the  neuritis. 

The  results  of  autopsical  examination  have  also  shown  the  actual  ex- 
istence of  neuritis  descendens. 


Rheumatic  Paralysis. 

Another  large  category  of  peripheral  paralyses  is  that  which  is  due  to 
so-called  rheumatic  or  atmospheric  influences,  and  is  known  as  rheumatic 
paralysis  (also  called  paralysis  a  frig  ore).  Our  knowledge  of  the  lesions 
which  are  produced  in  this  form  of  the  disease  is  purely  hypothetical,  so 
far  as  regards  the  milder  varieties,  which  never  prove  fatal.  The  paraly- 
sis was  formerly  supposed  to  be  reflex,  but  there  is  good  reason  to  be- 
lieve that  this  view  is  incorrect.  Thus,  Frerichs  reports  a  case  in  which 
a  child,  fet.  3  years,  became  paraplegic  after  having  sat  upon  a  cold  stone 
for  several  hours.  The  case  terminated  fatally,  and  the  autopsy  showed 
the  presence  of  exudative  meningitis  throughout  the  entire  spinal  canal. 
From  certain  of  the  symptoms  in  the  peripheral  forms  of  rheumatic  par- 
alysis, it  is  supposed  that  the  affection  is  due  to  various  grades  of  neu- 
ritis or  perineuritis,  which  may  sometimes  be  so  severe  as  to  lead  to 
degeneration  of  the  nerves  and  muscles,  such  as  we  have  described  as  the 
result  of  complete  division  of  the  nerve.  The  modus  operandi,  however, 
of  the  production  of  such  lesions  is  as  little  known  as  is  that   of  the  de- 


PERIPnERAL    PAP.ALYSIS.  177 

velopment  of  bronchitis  after  exposure,  etc.  Rheumatic  paralysis  develops 
either  as  a  consequence  of  cold  or  from  exposure  to  draughts,  especially 
when  the  patient  is  perspiring  and  is  not  exercising  at  the  time.  In  a  large 
proportion  of  cases  the  facial  and  ocular  muscles  are  involved,  and  as 
we  shall  see  at  a  later  period,  the  paralysis  may  vary  greatly  in  intensity; 
some  attacks  recover  spontaneously  in  a  few  da\'s,  others  are  incurable. 
Not  infrequently  rheumatic  paralysis  occurs  during  sleep,  when  the  pa- 
tient is  lying  in  a  draught.  It  may  develop  within  a  few  minutes  after 
the  operation  of  the  exciting  cause,  or  not  until  the  lapse  of  a  couple  of 
days.  It  is  usually  unattended  with  pain  or  other  sensory  disturbances, 
and  the  duration  of  the  disease  generally  varies  according  to  the  electrical 
reactions.  It  was  in  this  form  of  paralysis  that  the  "degeneration- 
reaction  ''  was  first  observed  by  Baierlacher.  In  the  most  severe  cases 
the  degeneration-reaction  is  as  well  marked  as  that  described  after  the 
complete  division  of  a  nerve,  and  in  some  all  electrical  reactions  of  the 
nerves  and  muscles  may  be  entirely  lost.  But  as  in  paralysis  from  injuries 
of  nerves,  there  are  numerous  gradations  between  these  severe  types  and 
tlie  slight  forms  in  which  the  muscular  and  nervous  electrical  reactions 
are  entirely  normal,  and  complete  recovery  occurs  within  a  few  days. 

The  more  intense  forms  of  rheumatic  paralysis  are  not  infrequently 
followed  by  spasms  and  contractures  of  the  affected  muscles.  The  lat- 
ter condition  is  very  liable  to  lead  to  permanent  deformity,  which  may 
seriously  interfere  with  the  progress  of  recovery. 

Atrophy  of  the  muscles  does  not  appear  to  be  as  marked  as  in  the  va- 
rieties of  paralysis  which  we  have  previously  described. 

Paealtsis  follo^vixg  Infectious  Diseases, 

The  occurrence  of  paralysis  as  a  sequence  of  various  general  diseases 
had  been  recognized  by  a  considerable  number  of  clinical  observers  for  a 
long  time,  but  it  is  only  within  the  past  fifteen  years  that  especial  atten- 
tion has  been  called  to  these  affections.  They  were  at  first  regarded  as 
purely  functional,  i.  e,,  no  anatomical  lesion  was  supposed  to  be  present 
in  these  cases;  but  the  pathological  investigations  of  the  last  decade  have 
shown  that  they  are  due,  in  the  majority  of  instances,  to  well-defined  lesions 
which  are  situated  sometimes  in  the  brain  and  spinal  cord,  sometimes  in 
the  peripheral  nerves  alone.  But  quite  a  number  of  cases  have  been  re- 
ported very  recently  in  which  even  the  most  careful  microscopical  exami- 
nation failed  to  show  the  presence  of  any  morbid  changes.  Dejerine  gives 
the  results  of  his  examination  of  three  cases  of  diphtheritic  paralysis,  in 
one  of  which  the  muscles  of  the  arms  and  neck,  in  another  both  arms,  and 
in  the  third  all  the  limbs  were  affected.  The  morbid  appearances  were 
similar  in  all  these  instances,  and  were  chiefly  confined  to  the  anterior 
roots  of  the  spinal  nerves.  The  nerve-sheaths  and  interstitial  connective 
tissue  showed  a  very  marked  increase  of  cellular  elements,  there  was  a 
similar  increase  in  the  nuclei  of  the  neurilemma,  and  the  white  substance 
of  Schwann  had  degenerated  into  a  sort  of  granular  mass;  many  of  the 
axis  cylinders  had  entirely  disappeared. 

Buhl  found,  in  the  same  disease,  that  the  roots  of  the  nerves  were 
thickened  and  had  undergone  yellow  softening  in  places;  the  sheaths  of 
the  nerves  and  their  interstitial  connective  tissue  showed  a  cellular  infil- 
tration which  Buhl  regarded  as  identical  with  the  diphtheritic  infiltration 
in  the  mucous  membrane  of  the  pharynx. 

Bernhardt  describes  the  following  appearances  in  a  case  of  paralysis 
12 


178  FUNCTIONAL    NERVOUS    DISEASES. 

of  the  radial  nerve  following  typhoid  fever:  the  capillaries  were  moder- 
ately distended  with  blood  globules,  and  numerous  capillary  hemorrhages 
were  noticed  along  the  walls  of  the  vessels;  the  axis  cylinders  had  disap- 
pecired  in  great  part,  and  the  white  substance  of  Schwann  had  undergone 
fatty  and  granular  degeneration. 

Similar  changes  have  been  noticed  in  the  paralyses  following  dysen- 
tery, measles,  etc.  We  may  also  remark  that  softening  and  disseminated 
myelitis  have  been  found  in  the  cord,  and  capillary  hemorrhages,  soften- 
ing, etc.,  in  the  brain  in  cases  of  central  paralysis  following  acute  infec- 
tious diseases. 

In  not  an  inconsiderable  number  of  autopsies,  however,  no  changes 
have  been  discovered,  notwithstanding  the  existence  of  well-marked  paral- 
ysis (which  may  even  have  been  the  direct  cause  of  death),  and  we  are 
therefore  forced  to  conclude  that  some  of  these  forms  may  be  due  to  the 
direct  paralyzing  action  of  the  specific  virus  upon  the  nerve-tissues. 

Clinical  History . — Paralysis  may  occur  as  a  sequel  of  diphtheria, 
dysentery,  whooping-cough,  variola,  scarlatina,  rubeola,  typhoid  fever, 
intermittent  fever,  pneumonia,  acute  articular  rheumatism. 

Some  of  these  affections  are  much  more  frequently  followed  by  paral- 
ysis than  others,  and  diphtheria  is  by  far  the  most  important  in  this  par- 
ticular. We  shall  therefore  devote  our  chief  attention  to  a  description 
of  diphtheritic  paralysis. 

There  does  not  appear  to  be  any  special  relation  between  the  severity 
of  the  primary  disease  and  the  frequency  of  occurrence  of  post-diphthe- 
ritic paralysis.  All  of  my  own  cases  have  occurred  after  mild  attacks  of 
diphtheria,  and  it  is  not  infrequent  to  find  the  paralysis  develop,  although 
the  throat  trouble  was  so  slight  that  the  case  would  have  been  called  one 
of  simple  pharyngitis,  were  it  not  for  the  existence  of  undoubted  cases  of 
di'phtheria  in  the  immediate  neighborhood. 

The  loss  of  motor  power  usually  develops  within  the  first  four  weeks 
after  the  beginning  of  the  disease,  although  in  rarer  instances  it  may  not 
occur  until  after  the  lapse  of  several  months.  In  the  beginning  the  muscles 
of  the  velum  palati  are  generally  involved;  this  is  shown  by  the  nasal  char- 
acter of  the  voice,  and  by  the  fact  that  the  regurgitation  of  fluids,  which 
may  have  been  present  in  the  early  period  of  the  disease,  now  reappears. 
Upon  inspection  the  velum  palati  and  uvula  are  found  to  have  lost  their 
tonicity,  and  perhaps  one  pillar  of  the  fauces  hangs  lower  than  the  other 
(we  have  not  met  with  any  reports  of  cases,  however,  in  which  only  one 
pillar  was  paralyzed).  Reflex  action  from  the  velum  palati  is  lost,  and 
the  parts  do  not  react  even  to  the  most  energetic  stimulation.  The  elec- 
trical reactions  of  the  affected  muscles  vary  considerably.  In  the  milder 
cases  they  are  unaffected,  in  others  there  is  simple  diminution  both  to  the 
faradic  and  galvanic  currents;  a  few  instances  have  been  reported  in 
which  the  faradic  excitability  was  abolished  and  the  galvanic  excitability 
markedly  increased.  The  latter  condition  has  been  noticed  by  Leube, 
Krafft-Ebing,  Rosenthal,  and  Joffroy,  so  that  its  occurrence  is  unques- 
tioned. 

In  the  majority  of  cases  some  of  the  muscular  structures  of  the  eye 
are  the  next  to  suffer.  Within  a  few  days  after  the  development  of  the 
faucial  disturbance  the  patients  suffer  from  paralysis  of  the  sphincter  of 
the  iris  and  the  tensor  muscle  of  the  choroid.  This  is  evidenced  by  dila- 
tation of  the  pupil  and  loss  of  the  power  of  accommodation,  so  that  the 
patient  can  see  distant  objects  distinctly,  while  vision  for  near  objects  is 
markedly  impaired. 


•  PERIPHERAL    PARALYSIS.  1 79 

More  rarely  some  of  the  other  ocular  muscles  are  also  involved,  es- 
pecially the  rectus  internus  and  externus.  Eulenburg  states  that  he  has 
sometimes  noticed  a  rapid  disappearance  of  the  paralysis  in  one  ocular 
muscle  (in  from  twenty-four  to  forty-eight  hours)  and  its  sudden  appear- 
ance in  another. 

Rosenthal  reports  the  occurrence  of  facial  paralysis  following  diph- 
theria. "  The  middle  paralyzed  muscles  of  the  face  had  lost  their  faradic 
contractility,  but  preserved  their  irritability  to  the  continuous  current. 
Even  after  the  disappearance  of  the  paralysis,  the  same  difference  existed 
■with  regard  to  the  action  of  the  two  currents." 

Paralysis  of  the  muscles  of  the  limbs  and  trunk  is  not  infrequently 
present.  It  is  rarely  observed  except  in  cases  in  which  the  velum  palati 
has  been  affected,  and  usually  develops  after  the  latter  begins  to  improve 
or  even  after  the  faucial  disorder  has  entirely  disappeared.  The  paralysis 
may  begin  either  in  the  upper  or  lower  limbs,  and  gradually  spreads  to 
the  rest  of  the  body.  The  muscles  of  the  neck  and  trunk  are  not  very  in- 
frequently involved,  and  in  such  cases  paralysis  of  the  diaphragm  is  liable 
to  occur.     These  forms  present  naturally  a  very  gloomy  prognosis. 

The  sensory  disturbances  are  very  slight,  and  usually  limited  to  a  feel- 
ing of  numbness,  with  or  without  anaesthesia,  in  the  paralyzed  parts. 
The  affected  muscles  are  very  apt  to  undergo  atrophy,  though  this  trophic 
change  does  not  develop  with  any  rapidity.  In  two  of  my  cases  loss  of 
power  in  the  lower  limbs  slowly  developed,  with  considerable  wasting  of 
the  muscles  and  some  numbness  and  anaesthesia.  In  both  of  these  cases 
incontinence  of  urine  occurred,  and  the  patients  did  not  possess  normal 
control  over  the  rectum.  Neither  of  these  individuals  had  suffered  from 
any  faucial  paralysis. 

The  electrical  reactions  of  the  affected  muscles  present  great  variations, 
and  various  forms  of  reactions  may  be  observed  in  the  same  individual, 
according  to  the  severity  of  the  paralysis.  In  a  case  recently  reported 
by  Fritz,*  the  muscles  of  the  calves  of  the  legs  only  responded  to  a 
very  strong  faradic  current,  while  the  muscles  of  the  ball  of  the  thumb 
were  entirely  inexcitable  to  this  current.  Exploration  with  the  galvanic 
current  showed  the  presence  of  marked  degeneration-reaction  in  the 
thumb  muscles.  As  the  paralysis  of  the  legs  increased,  the  degeneration- 
reaction  also  developed  in  the  muscles  of  the  calves. 

As  a  rule,  the  prognosis  of  post-diphtheritic  paralysis  is  very  good. 
The  patients  usually  recover  within  one  to  two  months,  especially  when 
the  aft'ection  is  limited  to  the  muscles  of  the  velum  palati  or  the  eye. 

The  favorable  prognosis,  the  occurrence  of  the  degeneration-reaction, 
and  the  results  of  autopsical  examination  (vide  p.  177),  render  it  very 
probable  that  the  majority  of  cases  of  post-diphtheritic  paralysis,  whether 
circumscribed  in  character  or  general,  are  due  to  an  affection  of  the  peri- 
pheral nerves  (cellular  infiltration,  etc.).  We  must  remember,  however, 
that  no  lesions  are  discovered  in  a  certain  proportion  of  cases. 

Typhoid  fever  ranks  next  in  importance  to  diphtheria  among  infectious 
diseases  as  the  cause  of  paralysis.  Like  diphtheria,  it  may  be  followed 
by  paralysis  in  different  parts  of  the  body  (ocular  muscles,  face,  paraple- 
gia, hemiplegia,  various  nerves).  These  paralyses  develop,  as  a  rule,  as 
a  sequence  of  the  disease,  but  they  have  also  been  observed  at  the  height 
of  the  affection.  They  differ  from  those  forms  following  diphtheria  in  the 
fact  that  they  usually  run  a  much  more  protracted  course.      With  this  ex- 

'  Charite-Annalen,  p.  255,  1880. 


180  FUNCTIONAL    NERVOUS    DISEASES. 

ception,  their  clinical  history  as  regards  atrophy  of  muscles,  electrical  re- 
actions, etc.,  is  exactly  similar  to  that  of  the  post-diphtheritic  affection. 
AYestphal  '  has  recently  reported  a  case  of  post-typhoid  paralysis,  which 
is  so  remarkable,  in  some  respects,  that  we  shall  republish  a  portion  of 
the  history  in  full: 

"  The  patient,  ret.  30  years,  recovered  from  an  attack  of  typhoid 
fever  with  a  paraparesis  of  the  lower  limbs.  At  the  end  of  nine  months 
she  was  unable  to  stand  or  walk;  the  peroneal  muscles  were  completely 
paralyzed,  the  tibiali  antici  retained  some  power.  No  sensory  disturban- 
ces, no  muscular  spasms;  the  bladder  and  rectum  acted  normally. 

"The  peronei  longi  and  gastrocnemii  muscles  could  be  contracted 
voluntarily  and  reacted,  though  very  feebly,  to  the  faradic  as  well  as  to 
the  galvanic  currents. 

"  Soth  tibiales  antici  onuscles  contracted  under  the  influence  of  the 
will  cm d  of  the  faradic  current,  cdthough  the  strongest  galvanic  current 
was  unable  to  jyrochice  the  slightest  contraction.  (This  remarkable  condi- 
tion is  called  isofaradic  reaction  by  Westphal.)  Under  the  influence  of 
treatment  with  the  faradic  and  galvanic  currents,  this  peculiar  phenome- 
non soon  disappeared.  The  tibiales  antici  muscles  gradually  began  to 
respond  to  the  galvanic  current,  in  about  two  months  presented  the  de- 
generation-reaction, and  later  became  normal." 

Variola,  rubeola,  scarlatina,  dysentery,  cholera,  erysipelas,  pneumonia, 
and  acute  articular  rheumatism  are  also  followed  by  paralyses  at  times, 
which  occur,  however,  much  more  infrequently  than  after  diphtheria  and 
typhoid  fever.  Their  clinical  history  is  in  all  respects  similar  to  that  of 
those  described  as  occurring  after  the  latter  diseases,  and  we  shall  there- 
fore refrain  from  entering  into  a  description,  which  would  be  a  mere  re- 
capitulation of  the  remarks  previously  made. 

Numerous  other  nervous  disturbances,  such  as  acute  ascending  spinal 
paralysis,  multiple  cerebro-spinal  sclerosis,  locomotor  ataxia,  etc.,  have 
been  observed  as  sequelae  of  the  diseases  just  mentioned,  but  their  dis- 
cussion is  beyond  the  scope  of  this  article. 


Toxic  Paralysis, 

The  next  class  of  cases  which  require  our  consideration  are  the  toxic 
parcdyses,  which  occur  in  consequence  of  j^oisoning  with  lead,  arsenic,  etc. 
Lead  is  svich  an  important  factor  in  the  production  of  paralytic  and  other 
nervous  disorders  that  we  will  enter  into  the  discussion  somewhat  in  de- 
tail. 

This  metal  may  be  introduced  into  the  system  in  a  thousand  different 
ways,  by  inhalation,  by  the  mouth  or  from  external  application  to  the  skin. 
Inhalation  may  occur  from  living-  in  newly-painted  rooms,  from  working 
in  factories  in  which  lead  is  employed  and  in  which  the  air  is  impregnated 
with  the  poisonous  particles  (as  in  white  lead  manufactories,  in  the  oper- 
ation known  to  painters  as  flatting,  etc.),  from  taking  snuff  which  has  been 
wrapped  in  lead  foil,  etc.  It  may  be  swallowed  in  confectionery  colored 
with  lead  salts,  in  articles  which  have  been  wrapped  in  lead  foil,  in  ale 
drawn  through  lead  pipes  (especially  that  which  is  drawn  early  in  the 
morning  and  has  lain  in  the  pipes  over  night),  in  water  drawn  from  lead- 
lined  cisterns,  in  bread,  the  flour  composing  which  has  been  ground  in 


'  Charite-Annaleu,  p.  376,  1880. 


PERIPHERAL    PARALYSIS.  181 

stones  filled  with  lead,  in  articles  cooked  in  vessels  lined  with  a  lead 
glaze,  etc.,  etc.  It  is  absorbed  through  the  skin  in  various  trades,  such 
as  plumbing,  from  handling  type,  using  hair-dyes  and  cosmetic,  etc. 

Among  1,213  cases  of  chronic  lead  poisoning  collected  by  Tanquerel 
des  Planches,  40G  occurred  in  white  lead  manufacturers,  305  in  house 
painters,  68  in  color  grinders,  63  in  red  lead  manufacturers,  54  in  earthen 
pottery  manufacturers,  52  in  type-founders,  47  in  carriage  painters,  35  in 
lapidaries,  and  33  in  ornamental  painters.  It  is  sometimes  extremely  dif- 
ficult to  determine  the  source  of  the  entrance  of  the  lead  into  the  system 
in  individual  cases,  and  in  several  instances  we  have  been  unable  to  dis- 
cover its  origin  although  the  most  indubitable  evidences  of  lead  poison- 
ing were  present. 

The  habits  of  the  patient  should  be  carefully  inquired  into,  and  his 
surroundings  examined.  Negative  statements  with  regard  to  the  impos- 
sibility of  the  entrance  of  lead  into  the  economy  should  never  be  accepted 
when  well-marked  symptoms  of  poisoning  are  present;  the  physician 
should  always  satisfy  himself  personally  of  the  condition  of  affairs. 
Children  are  very  apt  to  put  into  the  mouth  any  substance  with  which 
they  come  in  contact,  and  it  is  therefore  advisable,  in  cases  of  lead  poison- 
ing in  children,  to  carefully  examine  their  toys,  etc.  The  determination 
of  the  mgde  of  entrance  of  the  poison  into  the  system  is,  of  course,  of  the 
first  importance,  as  we  cannot  expect  any  improvement  in  the  symptoms 
until  its  further  admission  has  ceased. 

Lead  palsy  rarely  occurs  without  any  previous  symptoms  of  poisoning. 
The  patients  have  usually  suffered  for  a  long  time  from  obstinate  consti- 
pation, the  appetite  is  poor,  the  skin  assumes  a  peculiar  ashen-gray  ap- 
pearance, they  complain  of  a  metallic  taste  in  the  mouth,  the  tongue  is 
habitually  furred,  and  the  expired  air  exhales  a  disagreeable,  sickening 
odor.  The  pulse  is  usually  slow  and  hard,  the  surface  of  the  body  is  dry, 
the  gums  present  the  blue  line.  As  a  rule,  the  patients  have  suffered, 
prior  to  the  paralysis,  from  one  or  more  attacks  of  lead  colic.  Lead  pa- 
ralysis may  not  occur  until  the  above-mentioned  symptoms  have  lasted 
for  years,  in  other  cases  it  may  develop  after  a  very  short  exposure  to  the 
deleterious  influence  of  the  poison.  In  one  case  under  my  own  observation 
the  paralysis  began  to  develop  within  a  month  after  the  patient  had  be- 
gun work  in  a  white  lead  factory,  although  prior  to  that  time  he  had  been 
in  perfect  health  and  had  never,  so  far  as  I  could  ascertain,  been  exposed 
to  the  influence  of  lead. 

Lead  palsy  is  usually  bilateral,  but  in  some  cases  it  may  be  limited  to 
only  one  side.  In  the  majority  of  instances  the  extensor  muscles  of  the 
forearm  are  the  only  ones  affected  in  the  beginning  of  the  malady,  though 
other  groups  of  muscles  may  be  involved  at  a  later  period.  Before  the 
disease  develops,  the  patients  usually  suffer  from  tremor  of  the  arms  on 
exertion,  and  often  from  neuralgiform  pains  and  anaesthesia.  The  weak- 
ness of  the  muscles  generally  develops  gradually  and  increases  until  the 
production  of  paralysis.  Several  months  may  elapse  between  the  time  at 
which  the  patients  first  experience  weakness  of  the  limb  and  the  develop- 
ment of  complete  paralysis.  In  exceptional  cases,  however,  the  loss  of 
power  develops  quite  suddenly.  Thus  the  patient  may  retire  to  bed,  feel- 
ing entirely  well,  or  perhaps  complaining  of  numbness  in  the  arms,  and 
upon  waking  in  the  morning,  the  palsy  may  be  complete  or  almost  so. 
As  we  have  previously  stated,  the  extensor  muscles  of  the  forearm  are  the 
ones  usually  involved,  giving  rise  to  the  characteristic  deformity  known 
as  wrist-drop  (when  the  forearm  is  held  horizontal  in  complete  pronation, 


182  FUNCTIONAL    NERVOUS    DISEASES. 

the  hand  drops  down  almost  at  right  angles  to  the  arm,  and  in  the  sever- 
est cases  not  the  slightest  degree  of  extension  can  be  performed).  It  is  a 
remarkable  fact,  and  one  which  is  extremely  important  from  a  diagnostic 
point  ol  view,  that  the  supinator  longus  and  brevis  remain  unaffected  by 
the  disease,  though  these  muscles,  as  well  as  the  extensors,  are  supplied 
by  the  radial  nerve. 

Lead  palsy  is  usually  accompanied  by  rapid  atrophy  of  the  affected 
muscles  so  that  the  appearances  presented  are  very  characteristic.  Upon, 
examining  the  forearm  the  normal  rotundity  of  its  posterior  surface  is 
found  to  be  lost,  and  the  atrophy  is  sometimes  so  extreme  that  the  finger 
can  be  pressed  into  the  interosseous  space;  immediately  adjacent,  how- 
ever, the  prominent  supinator  longus  is  seen  passing  down  the  outside  of 
the  forearm  in  its  natural  proportions.  Although  the  freedom  of  the 
supinator  longus  from  paralysis  and  atrophy  is  almost  always  observed, 
there  are  some  exceptions  to  this  rule,  and  I  have  myself  observed  two 
cases  in  which  this  muscle  was  involved  to  the  same  extent  as  the  exten- 
sors. The  electrical  reactions  of  the  affected  muscles  vary  considerably. 
In  some  cases  there  is  merely  a  diminution  of  their  faradic  excitability, 
in  others  their  galvanic  excitability  also  diminishes.  These  reactions 
may  continue  throughout  the  entire  course  of  the  disease.  The  degen- 
eration-reaction is  also  observed  in  some  cases,  and,  it  is  said,  always 
m  those  forms  which  are  attended  with  very  rapid  muscular  atrophy. 
I  have  at  present,  however,  a  case  under  observation  in  which  the 
atrophy  is  so  great  that  the  finger  can  be  pressed  into  the  interosse- 
ous space,  but  in  which  the  faradic  excitability  of  the  muscles,  although 
not  very  distinct,  is  entirely  proportionate  to  the  small  amount  of  mus- 
cular fibre  left  intact;  the  galvanic  excitability  is  not  increased.  A  num- 
ber of  cases  of  this  kind  have  come  under  my  notice.  Eulenburg  has 
shown  that  increased  mechanical  and  reflex  excitability  of  the  muscles 
may  be  present  in  cases  in  which  their  galvanic  contractility  is  increased. 

It  has  been  stated  by  numerous  writers  that  in  cases  of  wrist-drop  the 
flexors  of  the  arm  are  also  partially  paralyzed.  This  statement  is  due  to 
a  mistake  in  observation,  as  can  be  readily  shown.  If  the  hand  is  flexed 
upon  the  forearm,  actual  measurement  will  show  that  the  flexor  muscles 
are  1^  to  1^  inches  shorter  than  when  the  hand  is  extended  (this  is  read- 
ily determined  by  making  a  mark  in  the  bend  of  the  elbow  and  measur- 
ing from  it  to  the  tips  of  the  fingers  while  flexed  and  extended).  But  as 
muscular  power  is  due  to  contraction  of  the  muscles,  the  power  of  the 
flexors  in  wrist-drop  must  necessarily  be  markedly  diminished,  since  the 
mere  position  in  this  affection  causes  a  shortening,  as  we  have  seen,  of 
1^  to  1-^  inches.  If  the  paralyzed  hand  is  held  by  the  observer  in  a  posi- 
tion of  moderate  extension  and  the  patient  be  then  directed  to  exert 
the  flexors,  their  power  will  be  found  undiminished. 

In  exceptional  cases  the  paralysis  does  not  begin  in  the  extensors  of 
the  forearm.  In  two  of  my  patients  the  loss  of  power  began  in  both  del- 
toids, and  had  progressed  to  such  an  extent  that  these  muscles  had  almost 
completely  wasted  away  before  the  extensors  began  to  be  affected.  In 
another  case  I  observed  paralysis  of  the  extensors  of  the  feet  before  those 
of  the  arms  became  implicated.  In  a  not  very  inconsiderable  number  of 
cases  the  paralysis  begins  in  the  usual  situation,  but  then  gradually 
spreads  to  other  muscles  of  the  body,  so  that  the  disease  may  run  the 
course  of  a  progressive  muscular  atrophy.     Buzzard '  mentions  an  inter- 

'  Brain,  p.  121,  vol.  i. 


PERIPHERAL    PARALYSIS.  183 

esting-  case  in  which  the  right  hand  and  the  left  foot  were  paralyzed;  the 
supinators  were  not  affected.  The  faradic  excitability  of  the  extensors 
was  lost  in  the  aifected  parts,  and  diminished  in  the  left  hand  and  rig-ht 
foot;  there  was  increased  excitability  to  galvanism;  no  blue  line  on  the 
gums.  The  diagnosis  was  chiefly  based  on  the  electrical  reactions  and 
the  freedom  of  the  supinators  from  paralysis.  Careful  examination  showed 
that  the  cistern  from  which  the  drinking-water  was  drawn  contained  a 
roll  of  lead  pipe  which  had  been  left  there  while  repairs  were  being  made. 

The  pathology  of  lead-paralysis  is  still  very  obscure.  In  cases  of 
chronic  lead-poisoning,  lead  has  been  found  in  the  brain,  cord,  muscles, 
bones,  etc.,  a  larger  quantity  being  found  in  the  spinal  cord  than  in  the 
muscles.  Hitzig  was  of  the  opinion  that  the  paralysis  was  due  to  the 
direct  deposit  of  the  metal  in  the  affected  muscles,  but  this  view  has  been 
successfully  combated  by  Bernhardt,  who  found  that  the  unaffected  su- 
pinator longus  contained  proportionally  almost  the  same  quantity  of  lead 
as  the  atrophied  extensor  muscles. 

The  anatomical  changes  in  this  disease  have  not  been  very  thor- 
oughly investigated.  Lancereaux  reports  one  case  in  which  the  cervical 
enlargement  of  the  spinal  cord  presented  a  soft  consistency  and  was  not 
as  large  as  normally.  Some  of  the  nerve-roots  springing  from  this  por- 
tion of  the  cord  were  atrophied,  and  the  nerve-fibres  had  undergone  gran- 
ular degeneration.  Vulpian  ^  found,  in  a  case  of  lead-paralysis,  marked 
poliomyelitis  with  colloid  degeneration  and  atrophy  of  some  of  the  ganglion 
cells,  an  increase  in  the  number  of  nuclei,  and  patches  of  sclerosis  in  the 
roots  of  the  cervical  enlargement  of  the  spinal  cord.  C.  V.  Monakow,'  who 
made  an  extremely  careful  examination,  corroborates  Vulpian's  observa- 
tion in  great  part.  Westphal,  Gombault,  and  Friedlander,  on  the  other 
hand,  found  no  changes  in  the  spinal  cord.  Various  lesions  have  been 
observed  in  the  radial  nerve  (granular  and  fatty  degeneration,  increase 
of  nuclei,  etc.),  but  no  definite  results  have  been  obtained,  and  it  is  unde- 
cided whether  these  changes  are  primary  or  secondary.  Mayor  ^  found 
the  following  changes  in  the  intramuscular  nerves  of  the  extensor  com- 
munis pollicis  in  a  case  of  lead-paralysis:  the  myeline  in  rounded  drops; 
disappearance  of  the  axis  cylinders;  nuclei  of  some  of  the  fibres  more 
numerous,  with  complete  disappearance  of  the  myeline;  the  sheath  of 
Schwann  persistent;  a  large  number  of  the  nerve-fibres  entirely  healthy. 

The  paralyzed  muscles  have  been  found  paler  than  normal,  the  trans- 
verse strife  not  well  marked,  and  the  nuclei  of  the  sarcolemma  increased 
in  numbers;  there  is  increase  of  the  interstitial  tissue,  and  a  new  develop- 
ment of  adipose  tissue. 

It  is  very  evident  from  these  manifold  changes  that  pathological  anat- 
omy has  not  yet  determined  the  real  nature  of  the  disease.  Hitzig's 
theory  of  a  local  affection  of  the  muscles  has  been  previously  referred  to, 
and  the  weak  basis  upon  which  it  is  founded,  pointed  out. 

The  question  as  to  the  peripheral  or  spinal  character  of  the  paralysis 
is  not  definitely  settled,  though  there  is  a  strong  tendency  at  present  to 
regard  it  in  the  light  of  an  affection  of  the  spinal  cord.  This  view  has 
received  additional  support  from  the  results  of  the  post-mortem  exami- 
nations made  by  Vulpian  and  Monakow,  to  which  we  have  previously  re- 
ferred. Remak  mentions,  as  one  of  the  strongest  arguments  in  favor  of 
the  spinal  origin  of  the  affection,  the  fact   that   the  muscles  usuallv  in- 

'  Mai.  du  systems  nervenx,  1879,  p.  158.  ^  j^j.^.^   f_  Psych.,  1880. 

■'  Gaz.  mt'd.  de  Paris,  19,  1877. 


184  FUNCTIONAL    NERVOUS    DISEASES. 

volved  belong  to  a  single  functional  group,  while  the  supinator  longus, 
althouo-h  it  is  supplied  by  the  same  nerve  as  the  extensors,  is  not  impli- 
cated except  in  rare  exceptions.  It  must  be  remembered,  however,  that 
cases  have  been  reported  in  which  the  spinal  cord  presented  no  changes. 

The  theory  that  the  disease  is  due  to  an  affection  of  the  peripheral 
nerves  is  based  upon  the  fact  that  lesions  of  the  radial  nerve  have  been 
found,  although  the  spinal  cord  was  intact,  and  also  upon  the  frequent 
occurrence  of  the  degeneration-reaction.  As  we  shall  see  later  on,  how- 
ever, this  latter  phenomenon  is  not  an  absolute  indication  of  the  peripheral 
character  of  the  paral3'^sis. 

We  must  therefore  conclude  that  the  true  pathology  of  lead-paraly- 
sis is  still  not  definitely  settled;  further  investigations  may,  however,  show 
that  the  disease  is  sometimes  peripheral,  sometimes  central  in  its  nature. 

The  introduction  of  arsenic  into  the  system  also  acts  as  a  cause  of 
paralysis,  though  much  more  rarely  than  lead.  Like  the  latter  it  may 
give  rise  to  wrist-drop,  due  to  paralysis  cf  the  extensors  with  escape  of 
the  supinators.  Eulenburg  has  seen  several  instances  of  this  kind  in 
workers  in  artificial  flowers.  My  own  experience  has  been  exceedingly 
limited  in  this  respect,  the  only  case  of  this  kind  which  has  come  under 
my  own  notice  being  one  of  paraplegia  following  acute  arsenical  poison- 
ing. As  the  bladder  and  rectum  were  affected  in  my  patient,  who  is  still 
under  observation,  I  am  led  to  regard  the  paralysis  as  probably  due  to 
subacute  myelitis.  The  majority  of  cases  of  arsenical  paral3^sis  assume 
the  pai^aplegic  form.  In  those  cases  in  which  the  paralysis  is  localized, 
the  symptoms  with  regard  to  atrophy  of  the  muscles,  electrical  reactions, 
etc.,  are  identical  with  those  observed  in  lead-palsy.  As  in  the  latter 
disease,  also,  it  is  doubtful  whether  the  paralysis  is  due  to  a  lesion  of 
the  peripheral  nerves  or  of  the  spinal  cord,  and  post-mortem  examinations 
are  entirely  wanting. 

Mercurial  poisoning  is  rarely  a  cause  of  localized  paralysis.  The 
long-continued  ingestion  or  inha,lation  of  mercury  gives  rise  to  mer- 
curial tremor,  an  affection  which  is  not  by  any  means  so  frequent  now 
as  it  was  in  former  times.  The  limbs  which  are  affected  with  the  tremor 
are  always  paretic,  and  in  very  exceptional  cases  the  tremor  disappears 
and  is  replaced  by  localized  paralysis  of  the  muscles.  Nothing  further  is 
known  with  regard  to  the  electrical  reactions  and  other  phenomena  pre- 
sented in  the  affected  muscles,  and  the  pathology  of  the  affection  is  equally 
obscure. 

Ischemic  Paralysis. 

A  rare  but  interesting  form  of  disease  is  that  known  as  ischfemic 
paralysis,  which  is  due  to  an  interference  with  the  proper  supply  of  arte- 
rial blood  to  the  affected  nerves  and  nmscies,  either  from  embolism  or 
occlusion  of  the  vessel  from  the  pressure  of  an  aneurism.  Very  few  cases 
of  this  character  have  been  observed,  and  I  shall  therefore  republish  the 
two  following  examples,  the  first  one  being  reported  by  Rosenthal,'  the 
second  by  Prof.   Mannkopf. 

Case  III. — "A  man,  set.  50  years,  stated  that  on  October  31,  18G9, 
he  was  suddenly  seized,  while  walking,  with  a  violent  pain  in  the  left  leg, 
rendering  motion  impossible,  and  necessitating  the  removal  of  the  patient, 

'  Clinical  Treatise  on  Diseases  of  the  Nervous  System,  p.  422. 


PERIPHERAL   PARALYSIS.  185 

on  the  following  day,  to  the  Vienna  General  Hospital.  Upon  examina- 
tion, a  solid  tumor  was  found  in  the  region  of  the  left  obturator  foramen, 
a  little  larger  than  a  chestnut,  pulsating  isochronously  with  the  crural 
artery,  and  presenting  no  bruit  on  auscultation. 

Two  days  afterward  I  found  the  left  thigh  much  colder  than  the 
right,  the  movements  of  extension  scarcely  appreciable,  and  the  electro- 
muscular  contractility  and  sensibility  considerably  diminished  in  the  ex- 
tensors of  the  thigh  (upon  comparison  with  the  corresponding  muscles  on 
the  healthy  side).  Upon  November  3d  (four  days  after  tlie  beginning 
of  the  disease),  the  electro-muscular  contractility  to  faradism  was  found 
to  be  abolished  on  the  anterior  surface  of  the  thigh.  Gangrene  of  the 
limb  then  set  in,  followed  by  chills,  and  the  patient  died  on  November 
24th. 

Upon  autopsy,  a  sacculated  aneurism,  as  large  as  a  walnut,  was  found 
in  the  neighborhood  of  the  obturator  foramen.  It  originated  from  the 
posterior  surface  of  the  left  crural  artery,  pushed  the  vessel  upward,  and 
opened  into  its  lumen  by  an  elliptical  opening  as  large  as  a  coffee-bean. 
The  wall  of  the  artery  was  thickened  around  this  opening,  and,  on  account 
of  the  strong  tension  existing  above  the  neck  of  the  aneurism,  the  calibre 
of  the  artery  was  narrowed  to  such  an  extent  that  it  only  permitted  the 
passage  of  a  small-sized  sound.  The  deep  femoral  artery  and  the  point 
of  emergence  of  the  popliteal  artery  were  obliterated  by  solid,  adherent 
thrombi.'' 

Case  IV. — "  The  patient  was  suffering  from  an  attack  of  acute  articular 
rheumatism,  during  the  course  of  which  an  acute  pain  suddenly  devel- 
oped in  the  left  calf  and  foot,  accompanied  by  a  sensation  of  cold  in  this 
region.  Paralysis  of  motion  and  sensation  developed  in  the  affected 
parts,  and  well-marked  degeneration-reaction  was  present  in  the  paralyzed 
muscles. 

Upon  physical  examination,  mitral  insufficiency  was  found,  and  there 
was  absence  of  pulsation  in  both  femoral  arteries. 

At  the  autopsy,  fibrinous  pJugs  were  found  at  the  bifurcation  of  the 
aorta  in  the  right  common  iliac  and  in  the  left  posterior  tibial  artery. 
The  spinal  cord  appeared  to  be  intact  ;  the  left  tibial  nerve,  a  short  dis- 
tance below  its  separation  from  the  left  peroneal  nerve,  presented  the 
changes  characteristic  of  parenchymatous  and  interstitial  neuritis  ;  the 
muscles  were  found  in  a  condition  of  myositis." 

When  the  occlusion  of  the  artery  is  not  complete,  or  when  the  collat- 
eral circulation  is  established  to  a  certain  extent,  the  paralysis  may  be  in- 
termittent in  character. 

This  was  noticed  in  one  of  Charcot's  patients,  in  whom  paralysis  of 
the  right  leg  occurred  from  aneurism  of  the  right  primary  iliac  ;  the  par- 
alysis always  disappeared  during  repose. 

Physiological  experiments  have  shown  that  this  form  of  paralysis  is 
due  to  loss  of  irritability,  occurring  first  in  the  nervous  structures  and 
then  in  the  muscles,  in  consequence  of  the  anasmia  of  these  parts.  When 
the  abdominal  aorta  is  compressed  in  animals,  paraplegia  and  anassthesia 
of  the  hind  limbs  is  produced.  It  has  been  found,  in  such  cases,  that 
the  irritability  of  the  spinal  cord  is  very  rapidly  lost;  that  of  the  peripheral 
nerves  in  from  three-quarters  of  an  hour  to  an  hour  after  the  aorta  has 
been  compressed,  while  the  irritability  of  the  muscles  persists  for  a  much 
longer  period. 


186  FUNCTIONAL    NEKVOUS    DISEASES. 


Syphilitic  Paealtsis. 

In  conclusion,  we  must  make  a  short  reference  to  the  influence  of 
syphilis  in  the  production  of  peripheral  paralysis.  In  very  exceptional 
cases  it  is  said  to  occur  within  a  short  time  after  the  first  develop- 
ment of  the  syphilitic  symptoms,  and  it  is  probable  that  in  these  cases 
the  paralysis  is  due  to  the  direct  action  of  the  syphilitic  virus  upon  the 
affected  nerves.  In  the  majority  of  cases,  however,  syphilitic  paralysis 
occurs  in  the  tertiary  stages.  It  is  then  due  to  pressure  upon  the  nerves 
from  adjacent  periostitis  or  exostoses,  or  to  the  development  of  gummata 
in  the  nerves  themselves.  The  larger  number  of  these  paralyses  affect 
the  cerebral  nerves,  especially  those  supplying  the  ocular  muscles.  Some- 
times merely  a  single  twig  of  one  of  these  nerves  is  implicated,  and  syphi- 
litic ptosis  (paralysis  of  the  levator  palpebrfe  superioris)  is  perhaps  one  of 
the  most  frequent  forms  of  this  variety  of  the  disease.  Zeissl  mentions  a 
case  in  which  a  syphilitic  exostosis  of  the  greater  sciatic  foramen  pro- 
duced pressure  upon  the  sciatic  nerve  and  gave  rise  to  paralysis. 

The  clinical  history  of  this  form  is  similar  to  that  due  to  pressure 
upon  the  nerves  from  other  causes,  and  we  may  therefore  refer  to  the 
remarks  made  upon  page  166,  et  seq.  Careful  examination  will,  how- 
ever, usually  reveal  the  existence  of  other  evidences  of  syphilis,  espe- 
cially in  its  cerebral  forms.  We  have  previously  entered  so  fully  into  a 
discussion  of  these  symptoms  that  it  is  unnecessary  to  recur  to  them  at 
this  period.  The  prognosis  of  syphilitic  peripheral  paralysis  is  usually 
very  good,  and  the  disappearance  of  the  disease  under  anti-syphilitic 
measures  is  an  excellent  diagnostic  sign. 


CHAPTER  II. 

DIAGNOSIS  AND  PROGNOSIS. 

The  first  question  to  determine  is  whether  the  loss  of  muscular  func- 
tion present  in  any  individual  case  is  really  paralytic  in  its  nature.  This 
can  only  be  done  by  carefully  inquiring  into  the  clinical  history,  and  thus 
excluding  those  cases  in  which  the  loss  of  motion  is  due  to  disease  of  the 
muscles,  bones,  joints,  or  ligaments. 

Care  should  also  be  taken  in  discriminating  between  the  immobility 
of  a  part  from  loss  of  power  in  the  muscles,  and  that  occasioned  by  the 
production  of  pain  upon  movements  of  the  part.  This  difficulty  is  fre- 
quently experienced  in  severe  cases  of  sciatica,  in  which  the  patients  are 
often  unable  to  move  the  limb  on  account  of  the  excruciating  agony  pro- 
duced by  the  slightest  movement  of  the  parts. 

In  infants  it  is  often  very  difficult  to  determine  the  exact  location  of 
any  paralysis  which  may  be  present.  This  is  due  to  the  fact  that  they 
are  unable  to  understand  our  directions,  and  also  because  the  adipose 
layer  of  the  skin  is  frequently  so  well  developed  that  it  hides  the  pres- 
ence of  muscular  atrophy,  even  though  the  latter  be  very  considerable 
in  amount.  I  have  very  often  been  unable  to  detect  any  difference  in 
the  measurements  of  the  limbs  in  chubby  infants,  although  one  of  the 
members  was  the  site  of  acute  infantile  paralysis,  and  the  complete  loss 
of  power  together  with  the  duration  of  the  disease  rendered  it  positive 
that  marked  atrophy  of  the  muscles  must  have  occurred. 

If  we  suspect  paralysis  of  any  set  of  muscles  in  a  child  too  young 
to  obey  our  orders,  we  may  often  determine  its  presence  by  holding  a 
bright  object  in  front  of  him  in  such  a  position  that  the  little  patient 
can  only  reach  it  by  calling  into  play  the  suspected  muscles.  If  this 
cannot  be  done  by  the  infant,  the  position  of  the  object  should  be  changed 
from  time  to  time,  and  the  movements  of  the  little  one  in  the  efforts  to 
reach  it  carefully  watched.  Some  information  may  also  be  obtained  by 
performing  various  passive  movements  of  the  parts,  and  noting  the  dif- 
ferences in  the  tonicity  of  the  muscles  or  in  the  active  resistance  which  is 
made. 

In  some  cases  of  paralysis  in  infants  a  mere  inspection  of  the  parts 
will  sviffice  to  make  a  diagnosis,  but  in  others  we  must  not  alone  go 
through  all  the  manipulations  mentioned  above,  but  must  resort  to  seve- 
ral examinations  before  we  arrive  at  a  definite  conclusion  with  regard  to 
the  exact  location  of  the  disease.  I  have  seen  not  a  few  gross  mistakes 
made  in  the  diagnosis  of  paralysis  in  children,  and  I  cannot  too  strongly 
enjoin  the  exercise  of  care  and  discrimination  in  the  examination  of  such 
patients  in  whom  we  suspect  its  presence. 

After  having  made  a  diagnosis  of  paralysis,  its  character,  whether 
peripheral  or  central  should  be  then  determined.  The  first  inquiry  made 
should  be  with  regard  to  the  cause  of  the  disease.  Thus,  there  can  be 
no   question  of  the  character   of   the   affection,  if   a  knife-wound  of  the 


188  PtJNCTlONAL    NERVOUS    DISEASES. 

ulnar  nerve  has  been  followed  by  paralysis  of  the  corresponding  muscles. 
In  very  many  instances  a  careful  examination  into  the  etiology  of  the 
paralysis  vv^ill  shed  full  light  upon  its  character,  in  others  no  cause  can  be 
determined,  while  in  not  a  few  it  may  have  acted  upon  the  central  ner- 
vous system  as  well  as  upon  the  periphery. 

In  the  majority  of  cases  there  are  certain  distinctive  qualities  which 
enable  us  to  distinguish  peripheral  from  central  paralysis.  In  the  latter 
we  very  rarely  find  the  loss  of  power  limited  to  a  few  muscles,  and  with 
the  exception  of  the  cerebral  nerves,  the  paralysis,  as  a  rule,  does  not 
affect  an  individual  nerve,  but  rather  groups  of  muscles  which  belong 
together  functionally.  In  peripheral  paralysis,  as  a  matter  of  course,  the 
loss  of  power  affects  those  muscles  to  which  the  affected  nerve  is  distrib- 
uted, though,  in  exceptional  cases,  the  nerve  is  only  partially  affected,  and 
only  certain  of  these  muscles  are  involved.  In  one  case,  however,  which 
came  under  my  notice,  and  which  I  published  in  the  Medical  Hecord,  Janu- 
ary 26, 1878,  a  spinal  hemiplegia  was,  in  all  probability,  due  to  peripheral 
causes.  This  case  presents  so  many  points  of  interest  that  I  shall  re- 
publish it  : 

Case  V. — Wm.  T.,  fet.  22  years;  patient  perfectly  healthy  until 
March  8, 1876,  when  he  suddenly  felt  pain  in  the  left  shoulder,  which  soon 
extended  into  the  other  shoulder  and  into  the  cervical  and  upper  dorsal 
regions  of  the  spine;  this  was  attended  with  strongly-marked  torticollis 
on  the  left  side.  The  next  day,  March  9th,  he  was  admitted  to  Roose- 
velt Hospital.  For  permission  to  publish  his  history  during  his  stay  in 
that  institution,  I  am  indebted  to  the  kindness  of  Dr.  Wm,  H.  Draper, 
under  whose  care  the  patient  was  for  a  part  of  the  time. 

On  March  13th  a  swelling  was  noticed  on  the  back  of  the  neck,  on  the 
left  side,  and  a  diagnosis  of  deep  abscess  was  made.  From  March  10th' 
to  20th,  the  patient's  temperature  varied  irregularly  from  100°  to  104°  F. ; 
pulse  rapid,  and  an  eruption  resembling  typhoid  appeared  on  the  back 
and  chest;  he  had  severe  pain  in  the  back  and  in  the  left  extremi- 
ties. From  March  20th  to  April  1st,  the  patient  had  complete  paralysis 
of  the  bladder.  He  now  began  to  suffer  from  a  feeling  of  "  a  tight  band  " 
around  the  lower  part  of  the  chest;  this  lasted  eight  to  ten  weeks. 
Paralysis  of  motion  now  began  to  show  itself  in  the  left  arm,  and  soon 
spread  to  the  left  leg;  there  was  also  some  anaesthesia  on  the  left  side  of 
the  body.  At  the  end  of  March  paralysis  was  almost  complete  on  the 
left  side.  On  April  2d  the  patient  began  to  slowly  regain  power  over 
the  paralyzed  parts;  the  ansesthesia  gave  way  to  hypertesthesia.  For  a 
week  succeeding  this  date  there  was  intense  pain  on  the  left  side;  the  left 
leg  and  arm  are  now  slightly  contractured;  some  pain  in  right  arm.  Dur- 
ing the  whole  illness  the  temperature  did  not  range  above  105°,  and  was 
very  irregular. 

The  patient  kept  on  steadily  improving,  and  was  discharged  from  hos- 
pital, July  19th.  During  his  sickness  he  had  fibrillary  twitchings  in 
the  muscles  of  the  left  side;  was  costive  from  the  beginning  of  the 
attack;  never  had  headache  or  other  cerebral  symptoms;  formication 
and  tingling  in  the  left  side  at  times.  The  patient  first  came  under  my 
own  observation  about  the  end  of  September,  1876.  He  then  had  partial 
left  hemiplegia;  the  left  arm  and  forearm  were  each  half  an  inch  smaller 
than  the  corresponding  parts  on  the  right  side;  the  movements  of  the 
lower  limb  are  much  more  affected  than  those  of  the  upper;  patient  drags 
the  limb  very  markedly,  and  must  use  a  cane;  he  has  a  feeling  of  numbness 


PERIPHERAL    PARALYSIS.  189 

in  the  adductors  of  the  thigh  and  flexors  of  the  leg;  sensation  otherwise 
normal;  reaction  of  muscles  to  electricity  is  normal  for  both  currents.  In 
the  left  rhomboid  minor  muscle  is  found  a  small,  indurated  mass,  which  is 
very  slightly  sensitive  to  pressure. 

The  patient  was  treated  by  local  faradization.  About  the  end  of  De- 
cember, 187G,  the  swelling  in  the  rhomboid  muscle  became  tender;  it  per- 
sisted until  the  middle  of  January,  and  then  disappeared  for  a  few  weeks, 
to  reappear  again  in  various  places  in  the  right  and  left  rhomboidei  and 
levatores  anguli  scapulse.  On  February  38th  he  drew  my  attention 
to  a  small  abscess  situated  over  the  third  and  fourth  dorsal  vertebrse; 
this  was  opened,  and  discharged  a  small  amount  of  thick  pus.  On  March 
1st  a  very  small  piece  of  bone  was  discharged  through  the  opening,  and 
the  next  day  the  patient  entered  Bellevue  Hospital,  where  Dr.  Jacobi  laid 
open  a  sinus  extending  four  inches  upward  along  the  course  of  the  spi- 
nous processes;  the  sinus  was  probed,  but  no  dead  bone  was  found.  On 
the  posterior  superior  angle  of  the  left  scapula  I  obtained  a  feeling  of 
crepitus,  and  the  patient  winced  when  this  spot  was  pressed  upon.  On 
July  1st  he  returned  to  work,  feeling  quite  well.  On  November  20th  he 
again  reported  to  me  with  the  sinus  completely  closed,  and  the  swell- 
ing and  induration  in  the  muscle  entirely  gone;  there  is  still  a  slight  feel- 
ing of  roughness  over  the  posterior  superior  angle  of  the  scapula.  The 
muscular  power  on  the  left  side  is  completely  restored. 

The  case  is  evidently  one  of  inflammation  within  the  spinal  canal;  the 
exact  location  of  the  lesion  is  a  matter  of  considerable  obscurity.  In  my 
opinion  the  diagnosis  lies  between  meningitis  spinalis  simplex  and  peripa- 
chymeningitis spinalis.  The  latter  term  implies  an  inflammation  outside 
of  the  dura  mater  of  the  cord,  and  any  paralysis  produced  by  such  a  lesion 
must  necessarily  be  of  a  peripheral  nature.  My  reasons  for  adopting  the 
latter  view  are  as  follows: 

1.  All  of  the  symptoms  of  the  disease  can  be  readily  explained  on  the 
theory  that  it  was  due  to  a  suppurative  inflammation  in  the  cellular  tissue 
between  the  dura  mater  and  the  vertebrae. 

2.  Some  of  the  characteristic  symptoms  of  meningitis  were  absent. 

a.  There  Avere  no  cerebral  symptoms  whatever.  A  case  of  severe  spinal 
meningitis,  especially  when  the  cervical  portion  of  the  meninges  is  affected, 
without  the  supervention  of  any  cerebral  manifestations,  is  an  exceedingly 
rare  clinical  experience. 

b.  No  tenderness  was  observed  along  the  spinous  processes,  and  none 
of  the  rigidity  of  the  spine  so  characteristic  of  spinal  meningitis. 

c.  There  was  absence  of  increased  reflex  excitability. 

3.  Paralysis  came  on  later  than  is  usual  in  cases  of  meningitis  simplex. 

4.  In  cases  of  meningitis,  attended  with  as  much  paralysis  as  was  pres- 
ent in  this  case,  there  is  usually  a  coexistent  myelitis,  and  recovery  is 
therefore  not  so  complete  as  in  this  instance. 

5.  If  we  examine  the  clinical  history  carefully  we  will  find  that  the 
local  symptoms  were  chiefly  confined  to  the  left  side  of  the  body.  The 
case  was,  in  reality,  a  spinal  hemplegia,  and  differs  from  all  others 
hitherto  described  in  the  fact  that  motion  and  sensation  were  affected  on 
the  same  side.  The  power  of  voluntary  motion  was  very  much  diminished 
on  the  affected  side,  while  the  disorders  of  sensation,  consisting  of  formi- 
cation and  tingling,  hyperesthesia  of  the  skin,  intense  pains,  and  then 
numbness,  were  also  confined  almost  exclusively  to  the  left  side  (with  the 
exception  of  a  certain  amount  of  .pain  in  tihe  right  arm  during  a  short 
period). 


190  FUNCTIONAL    NERVOUS   DISEASES. 

These  facts  prove  conclusively,  to  my  mind,  that  the  diseased  process 
must  have  produced  pressure  upon  the  roots  of  the  nerves  on  the  whole 
left  side  of  the  spinal  canal,  and  while  it  would  be  highly  improbable 
that  a  meningitic  process  should  be  limited  to  the  whole  length  of  only 
one  lateral  half  of  the  cord,  it  is  readily  conceivable  that  this  should  take 
place  in  the  connective  tissue  surrounding  the  dura  mater,  where  the  dis- 
ease is  not  so  likely  to  spread  in  all  directions  as  on  a  serous  membrane. 

A  very  interesting  question  presents  itself  to  our  notice  when  we  come 
to  consider  the  etiology  of  the  affection.  Was  the  inflammatory  exuda- 
tion within  the  substance  of  the  rhomboid  muscle  the  primary  cause  of 
the  23eripachymeningeal  inflammation,  or  was  it  secondary  to  this  inflam- 
mation ? 

Although  it  is  impossible  to  absolutely  determine  the  connection  be- 
tween these  two  trains  of  occurrences,  I  think  that  the  weight  of  evidence 
and  probability  is  strongly  in  favor  of  the  first  assumption. 

A  review  of  the  biography  of  the  subject  will  throw  some  light  upon 
the  question.  After  very  diligent  search  I  have  been  able  to  find  records 
of  only  seven  cases  of  this  disease,' 

I  have  found  that  among  the  seven  cases  hitherto  reported,  five  were 
secondary  to  inflammation  outside  of  the  spinal  canal,  and  two  were  ap- 
parently primary.  The  a  priori  evidence  is,  therefore,  in  favor  of  the 
secondary  origin  of  the  affection  in  our  case. 

Positive  evidence,  however,  is  not  wanting  to  point  in  the  same  direc- 
tion. In  the  first  place,  my  patient  states  that  he  noticed  the  swelling 
in  the  neck  on  the  first  day  of  his  admission  to  Roosevelt  Hospital,  thus 
showing  that  the  inflammation  in  the  external  tissues  was  at  least  coinci- 
dent, in  point  of  time,  with  the  beginning  of  the  spinal  affection,  and  in 
all  probability  antedated  it.  Secondly,  the  discharge  of  a  piece  of  bone 
from  the  fistula,  together  with  the  fact  that  I  obtained  crepitus  over  the 
superior  posterior  angle  of  the  scapula,  in  the  immediate  neighborhood  of 
which  the  swelling  first  appeared,  is  quite  conclusive  to  my  mind  that  the 
morbid  process  was  originally  a  necrosis  of  a  portion  of  the  scapula,  and 
that  the  pus,  instead  of  bursting  outward,  passed  inward,  through  the  in- 
tervertebral foramina,  and  there  set  up  a  suppurative  inflammation  around 
the  dura  mater. 

The  occurrence  of  trophic  changes,  especially  the  development  of 
marked  atrophy  of  the  muscles,  is  also  a  very  valuable  sign  of  the  periph- 
eral nature  of  an  attack  of  paralysis.  The  only  central  diseases  in  which 
this  symptom  occurs  are  acute  spinal  paralysis  of  infants  and  adults  (ante- 
rior poliomyelitis),  progressive  muscular  atrophy,  and  glosso-labio-laryn- 
geal  (bulbar)  paralysis.  But  these  affections  are  readily  distinguished  by 
characteristic  symptoms.  Acute  spinal  paralysis  frequently  begins  with 
fever  and  symptoms  of  cerebral  or  spinal  irritation,  the  paralysis  is  usually 
more  widespread  in  the  beginning  than  it  is  after  the  lapse  of  a  certain 
period,  and  sensory  disturbances  are  generally  absent  altogether.  In  pro- 
gressive muscular  atrophy,  the  course  of  the  disease  is  slow,  the  paralysis 
keeps  pace  continuously  with  the  atrophy  of  the  muscles,  and  the  latter 

'Mr.  John  Simon:  "Transactions  of  the  London  Pathological  Society,"  1855; 
Traube  :  Berlin  Medical  Society,  1863  (two  cases) ;  Mannkopf  :  Berlin  Medicinische 
Wochenschrift,  18G4 ;  Mueller:  Ueber  Peripachymeningitis  Spinalis,  Koenigsberg-, 
1868 ;  Leyden :  Klinik  der  Rueckenmarkskrankheiten  (no  autopsy) ;  Leyden :  Berhn 
Klin.  Wochenschrift,  December  17,  1879. 


PEKIPHERAL   PARALYSIS.  191 

usually  pursues  a  definite  course,  first  affecting  certain  of  the  small  mus- 
cles of  the  hands,  then  the  shoulders  or  forearms,  etc.  In  this  affection, 
also,  sensory  disturbances  are  entirely  wanting.  In  bulbar  paralysis  the 
association  of  facial,  glossal,  and  laryngeal  paralysis  is  so  characteristic 
that  the  affection  cannot  readily  be  mistaken,  although  a  deterniinatinn 
of  the  exact  location  and  nature  of  the  primary  lesion  may  be  extremely 
difficult. 

The  presence  of  the  degeneration-reaction  is  another  very  important 
sign  of  peripheral  paralysis.  This  symptom  is  also  observed  in  the  dis- 
eases which  we  have  mentioned  above,  with  the  exception  of  progressive 
muscular  atrophy.  Erb  has,  however,  reported  a  case  of  the  latter  dis- 
ease in  which  this  symptom  was  present.  Leyden,  in  his  remarks  upon 
the  case  of  multiple  neuritis  to  which  we  have  referred  on  page  170 
throws  out  the  suggestion  that  the  degeneration-reaction  may  only  occur 
in  spinal  diseases  when  they  are  accompanied  by  descending  neuritis, 
and  that  Erb's  case  of  progressive  muscular  atrophy  may  have  been  of 
this  kind.  However  this  may  be,  these  diseases  of  the  spinal  cord  are 
usually  easily  recognizable,  and  we  must  therefore  regard  the  degenera- 
tion-reaction as  one  of  the  most  valuable  symptoms  of  peripheral  paral- 
ysis. 


CHAPTER  III. 

TREATMENT. 

The  therapeutic  measures  at  our  command  in  peripheral  paralysis 
vary  with  the  etiology  of  the  affection,  and  we  shall  therefore  devote 
a  few  words  to  the  treatment  of  each  special  variety. 

Acute  neuritis,  if  unchecked,  is  apt  to  become  chronic,  and  we  should 
therefore  endeavor  to  cut  short  the  neural  inflammation  as  speedily  as 
possible.  One  of  the  main  indications  is  complete  rest  of  the  affected  part, 
and  when  this  can  be  effected  in  no  other  way,  a  splint  should  be  em- 
ployed. The  pain,  which  is  usually  intense,  may  be  reKeved  by  hypoder- 
mic injections  of  morphine  repeated  with  sufficient  frequency  to  produce 
comparative  ease.  Locally  we  may  employ  cold,  preferably  in  the  form 
of  an  ice-bladder,  which  is  applied  continuously  (it  should  not  be  taken 
off  after  a  few  hours,  as  the  latter  plan  merely  succeeds  in  increasing 
the  local  congestion).  Whenever  the  track  of  the  nerve  is  swollen  and 
cedematous  it  is  advisable  to  apply  a  number  of  leeches  along  its  course. 
As  soon  as  the  inflammation  passes  into  the  chronic  stage  these  meas- 
ures should  be  discontinued,  as  they  then  become  useless. 

In  chronic  neuritis  we  have  to  deal  with  a  very  obstinate  affection. 
In  this  also  we  should  endeavor  to  secure  rest  to  the  parts,  though  not  so 
complete  as  in  acute  neuritis,  on  account  of  the  long  duration  of  the 
disease.  Counter-irritation  often  proves  very  serviceable,  especially 
when  there  is  any  tendency  to  an  upward  spread  of  the  inflammation. 
I  generally  make  use  of  pieces  of  fly-blister  about  an  inch  square,  one 
of  which  is  first  applied  at  the  uppermost  portion  of  the  nerve,  which  is 
found  to  be  tender  on  pressure.  As  soon  as  this  begins  to  heal  another 
square  of  the  blister  is  applied  directly  below  it,  and  this  plan  is  con- 
tinued until  the  whole  course  of  the  nerve  has  been  treated  in  the  same 
manner.  This  is  very  useful  in  relieving  tenderness  of  the  nerve,  and  it 
has  also  seemed  to  me  to  be  very  efficacious  in  checking  the  progress  of 
neuritis  ascendens.  When  pain  forms  a  prominent  symptom  I  often  re- 
sort to  the  actual  cautery,  applied  along  the  entire  length  of  the  affected 
nerve  as  far  as  this  is  practicable.  This  measure  usually  produces  con- 
siderable improvement,  but  the  relief  is  only  temporar}^,  as  a  rule,  and 
the  pain  soon  returns  with  its  former  severity.  Another  excellent  palliative 
is  the  use  of  the  hot  douche.  Several  pitcherfuls  of  hot  water  (as  hot 
as  the  patient  can  bear)  should  be  slowly  poured  upon  the  affected  parts 
from  a  height  of  a  couple  of  feet;  this  may  be  done  twice  a  day  for  sev- 
eral weeks  or  even  a  few  months  without  interruption.  This  plan  is  not 
alone  valuable  in  checking  pain,  but  is  also  one  of  the  most  useful  meas- 
ures at  our  command  for  the  relief  of  the  contracture  of  the  muscles 
and  the  tenderness  and  partial  ankylosis  of  the  joints  which  are  so  apt 
to  develop  during  the  course  of  long-standing  neuritis. 

Electricity  is  also  indispensable.     The  galvanic  current  should  alone 


PERIPIIEKAL   PARALYSIS.  193 

be  used;  the  anode  may  be  applied  over  the  course  of  the  nerve,  and 
the  cathode  at  some  indifferent  point  farther  up  the  limb;  the  current 
should  be  applied  continuously,  strong  enough  to  produce  decided  red- 
ness of  the  skin  and  a  smart  burning  sensation  at  the  situation  of  the 
electrodes.  The  application  may  be  repeated  daily  or  every  other  day, 
each  sitting  lasting  four  or  five  minutes.  So  long  as  the  affected  nerve 
manifests  pain  and  tenderness  on  pressure  the  electrical  current  should 
only  be  employed  in  the  manner  described.  I  have  seen  no  good  effects 
under  such  circumstances  from  applying  electricity  directly  to  the  para^ 
lyzed  muscles.  The  nutritive  disturbances  in  the  muscles  are  due  to  the 
condition  of  the  nerves,  and  we  cannot,  therefore,  hope  for  much  im- 
provement of  the  paralysis  until  the  inflammation  of  the  nerves  has  sub- 
sided. 

The  constant  galvanic  current  is  not  alone  useful  in  relieving  pain 
and  diminishing  the  severity  of  the  neural  inflammation,  but  also  in 
relieving  contracture  of  the  paralyzed  muscles.  After  the  neuritis  has 
entirely  subsided  we  may  apply  the  electrical  current  directly  to  the 
paralyzed  muscles.  In  those  cases  in  which  the  faradic  current  does  not 
cause  contraction  of  the  muscles  it  is  useless  to  resort  to  this  form  of 
electricity.  Galvanism  should  then  be  employed,  the  current  being 
interrupted  by  means  of  an  "interrupter"  in  the  handle  of  one  elec- 
trode ;  interruption  of  the  current  (and  therefore  contraction  of  the 
muscles)  may  also  be  obtained  by  stroking  the  paralyzed  muscles  with 
one  electrode,  the  other  being  held  steadily  in  one  position.  The  current 
should  be  merely  strong  enough  to  produce  visible  muscular  contractions, 
the  sittings  occurring  daily  or  every  other  day.  When  the  muscles 
respond  to  faradism  this  current  should  be  employed  in  preference,  the 
application  being  made  directly  over  the  paralyzed  muscles.  In  severe 
forms  of  the  disease  we  must  be  prepared  to  exercise  great  patience, 
and  I  have  not  infrequently  employed  electricity  steadily  in  these  cases 
for  periods  varying  from  six  months  to  a  year  before  any  decided  im- 
provement was  obtained. 

Passive  motion  and  massage  sometimes  prove  very  useful  in  keeping 
up  the  nutrition  of  the  atrophied  muscles,  in  overcoming  contracture, 
and  in  relieving  ankylosis.  These  latter  symptoms  may  offer  some  of 
the  most  serious  obstacles  to  recovery  after  the  inflammation  of  the 
nerve  has  passed  away,  and  we  should  therefore  direct  all  our  energies 
toward  their  removal. 

Very  little  can  be  done  in  chronic  neuritis  in  the  way  of  internal 
medication.  The  only  internal  remedies  which  I  have  employed  in  this 
affection  are  iodide  of  potassium  and  the  fluid  extract  of  ergot,  either 
separately  or  combined.  The  doses  need  not  exceed  fifteen  grains  of  the 
former  or  one  drachm  of  the  latter.  I  am  unable  to  make  any  positive 
statements  with  regard  to  the  efficacy  of  these  drugs,  as  I  have  always 
employed  them  in  combination  with  some  of  the  measures  which  have 
been  recommended  above.  I  have  often  thought,  however,  that  they 
possess  a  certain  remedial  value.  No  mention  has  been  made  of  the  use 
of  opium  in  any  form  to  relieve  the  pain  of  neuritis,  because  I  am  firmly 
convinced  that  it  should  only  be  employed  as  a  last  resort  in  this 
disease. 

Any  considerable  experience  with  cases  of  this  disease  will  serve   to 

dispel    the    sanguine    expectations   which    may  have   been   formed  with 

regard  to  the  effect  of  therapeutic  measures,  but  we  should  not,  on  the 

other  hand,  adopt  the  expectant  plan  of  treatment.     The  employment  of 

13 


194  FUNCTIONAL    NERVOUS    DISEASES. 

persistent  and  judicious  measures  will  generally  produce  considerable 
relief  and  often  furnish  very  gratifying  results. 

When  the  paralysis  is  due  to  compression  of  the  nerves  by  overlying 
tumors,  exostoses,  cicatrices,  etc.,  the  pressure  may  sometimes  be  relieved 
by  suitable  surgical  measures.  In  some  cases,  as,  for  instance,  when  a 
tumor  is  directly  connected  with  the  tissue  of  the  nerve,  it  becomes 
necessary  to  extirpate  a  portion  of  the  latter.  When  the  excised  por- 
tion is  not  too  large  the  cut  ends  may  be  brought  into  coaptation  by 
means  of  sutures  (which  are  preferably  passed  through  the  sheath  of  the 
nerve  or  the  connective  tissue  immediately  adjacent),  and  a  proper  posi- 
tion given  to  the  limb.  It  would  appear  from  the  unanimous  testimony  of 
surgeons  that  suture  of  the  nerves  will  not  cause  immediate  union  of  the 
cut  ends,  though  it  may  hasten  regeneration.  In  cases  of  this  kind 
considerable  room  is  left  for  the  display  of  ingenuity  on  the  part  of  the 
surgeon,  and  general  rules  are  of  very  little  value. 

In  ischasmic  paralysis  nothing  can  be  directly  done  to  remove  the  offend- 
ing cause,  since  no  internal  medication  will  hasten  in  the  least  the  ab- 
sorption of  a  clot — in  reality,  a  foreign  body — in  a  vessel.  The  most  that 
can  be  done  in  such  cases  is  to  keep  the  parts  warm  by  the  application 
of  bottles  filled  with  warm  water,  or  thick  rolls  of  cotton-batting,  and  to 
pay  careful  attention  to  the  general  condition  of  the  patient  in  order  to 
maintain  the  circulation.  The  only  chance  of  recovery  lies  in  the  pros- 
pect that  the  collateral  circulation  may  be  re-established  with  sufficient 
vigor  to  nourish  the  affected  nerves  and  muscles  before  the  structure  of 
the  latter  has  been  irreparably  impaired. 

The  treatment  of  toxic  paralysis  turns  chiefly  upon  that  of  lead  pal- 
sy. The  iodide  of  potassium  has  been  employed  in  this  affection  since  its 
introduction  by  Melsens,  but  the  question  of  its  real  utility  is  still  unde- 
cided. In  conformity  with  the  usual  practice,  however,  I  have  always 
administered  it  in  small  doses  in  these  cases.  If  it  should  interfere  with 
digestion  it  must  be  discontinued  at  once,  as  the  disease  is  usually  accom- 
panied by  a  certain  degree  of  general  cachexia,  and  nothing  should  there- 
fore be  done  which  would  interfere  in  the  least  with  the  nutrition  of  the 
body.  It  is  unnecessary  to  state  that  tonic  remedies  should  be  employed 
to  suit  the  individual  case.  Warm  baths  often  prove  of  decided  advan- 
tage in  lead  paralysis,  as  they  tend  to  hasten  elimination  of  the  poison 
through  the  integument.  Sulphur  baths  have  also  been  highly  recom- 
mended for  the  same  purpose,  as  it  was  supposed  that  the  lead  would 
combine  with  the  sulphur  present  in  the  bath.  But  this  combination 
could  only  occur  with  such  portions  as  had  already  been  excreted,  and  we 
therefore  believe  that  the  advantage  to  be  derived  from  a  sulphur  bath 
can  be  obtained  with  equal  readiness  from  an  ordinary  warm  bath.  Elec- 
tricity also  plays  an  important  therapeutical  part  in  the  affection  under 
discussion.  As  a  rule,  the  reaction  of  the  paralyzed  muscles  to  the  fara- 
dic  current  is  diminished,  and  in  severe  cases  is  entirely  lost.  In  these 
cases  the  interrupted  galvanic  current  is  indicated,  the  applications  be- 
ing made  daily  for  a  period  of  five  to  ten  minutes.  We  should  not,  how- 
ever, forget  to  mention  that  quite  a  number  of  cases  have  been  reported 
in  which  the  persistent  application  of  the  faradic  current  led  to  recovery, 
although  the  paralyzed  muscles  did  not  respond,  at  first,  to  this  current. 
This  is  explained  by  the  fact  that  faradism  increases  the  irritability  of  a 
nerve,  even  when  it  is  insufficient  to  produce  muscular  contraction  ;  this 
fact  has  been  proven  by  physiological  experiments.  We  not  infrequently 
observe  in  lead  paralysis  that  the  voluntary  power  is  entirely  restored,  al- 


PEEIPIIERAL   PAEALTSIS.  195 

though  the  electrical  reactions  of  the  affected  muscles  are  still  below  the 
normal. 

In  lead  palsy  the  extensors  are  kept  continuously  on  the  stretch,  and 
this  increased  tension  is  an  obstacle  to  the  progress  of  recovery.  Various 
devices  have  been  resorted  to  in  order  to  overcome  this  feature,  but  we 
shall  refer  to  these  measures  in  the  chapter  on  paralysis  of  the  radial 
nerve.  When  very  marked  atrophy  of  the  muscles  has  occurred  the 
progress  of  recovery  is  usually  extremely  slow,  and  in  many  of  these  cases 
a  year  may  elapse  before  any  considerable  amount  of  improvement  has  oc- 
curred. In  some  instances,  indeed,  the  prognosis  is  extremely  unfavor- 
able, despite  the  most  patient  and  judicious  measures  of  treatment,  and 
recovery  never  occurs.     Such  cases  are,  however,  exceptional. 

Rheumatic  paralysis  sometimes  requires  little  or  no  treatment.  As 
we  have  shown  in  the  course  of  our  remarks  on  the  clinical  history  of  this 
form  of  paralysis,  the  milder  varieties  may  occur  spontaneously  within  a 
period  varying  from  a  few  days  to  two  weeks.  Of  course  no  treatment 
whatever  is  required  in  these  cases.  In  severe  forms,  if  seen  within  a  few 
days  after  the  beginning  of  the  paralysis,  it  is  perhaps  advisable  to  apply 
counter-irritation  in  the  form  of  a  fly-blister,  as  near  the  locus  morbi  as 
possible,  or  to  place  several  leeches  in  the  same  position. 

Strychnia  has  been  recommended  by  many  authorities  in  these  cases. 
The  high  repute  of  this  remedy  is  undoubtedly  due  to  the  fact  that  it  has 
been  frequently  employed  in  those  mild  forms  which  recover  spontane- 
ously, and  the  rapid  improvement  has  then  been  attributed  to  the  use  of 
the  drug.  For  my  own  part,  I  may  safely  state  that  I  have  never  seen  the 
slightest  good  effects  from  the  administration  of  strychnia  in  any  form  of 
peripheral  paralysis.  Nor  do  I  well  see  how  it  could  exert  any  beneficial 
action.  The  effect  of  strychnia  is  merely  to  increase  the  reflex  excitabil- 
ity of  the  spinal  cord,  and  physiological  experiments  have  shown  that  the 
irritability  of  the  peripheral  nerves  remains  unaffected  by  its  use. 

The  good  effects  of  electricity  have  also  been  over-estimated,  and  for 
the  same  reason  that  holds  good  with  regard  to  the  use  of  strychnia.  In 
severe  forms,  however,  it  is  the  only  agent  at  our  command  which  prom- 
ises success.  The  same  rules  hold  good  concerning  its  application  as 
those  which  we  have  laid  down  with  regard  to  lead  palsy.  In  rheumatic 
paralysis,  we  should  never  despair  of  recovery  so  long  as  the  slightest 
muscular  reaction  is  obtained  by  either  current.  In  fact,  improvement 
may  even  occur,  although  the  nerves  and  muscles  have  ceased  entirely  to 
respond  to  electricity,  as  I  found  in  one  case  in  which  complete  recovery 
was  obtained,  although  all  electrical  reaction  had  disappeared  for  a  period 
of  a  couple  of  months.  The  galvanic  current  was  steadily  employed,  how- 
ever, during  this  entire  time,  after  which  faint  reactions  to  this  current 
became  apparent. 

The  treatment  of  paralyses  following  infectious  diseases  is  identical 
with  that  of  the  rheumatic  forms. 


CHAPTEE  lY. 

PARALYSIS  OF  THE  OCULAE  MUSCLES. 
General  Remarks. 

We  shall  devote  very  little  attention  to  the  consideration  of  paralysis 
of  the  ocular  muscles,  since  this  affection  falls  more  naturally  under  the 
care  of  the  ophthalmologist,  and  we  must  therefore  refer  for  fuller  details 
to  the  standard  works  on  diseases  of  the  eye. 

The  slightest  amount  of  paralysis  in  any  of  the  ocular  muscles  will 
give  rise  to  a  diminished  power  of  motion  of  the  eyeball  in  the  direction 
Vi^hich  is  dominated  by  the  muscle  in  question.  This  loss  of  power  gives 
rise  to  a  diminution  of  the  absolute  and  of  the  relative  mobility  of  the  globe. 
The  diminution  of  the  former  is  much  slighter  than  that  of  the  latter, 
which  may  be  absent  altogether  when  the  paresis  of  the  muscle  is  not 
well  marked.  This  is  due  to  the  fact  that  in  testing  the  absolute  mobil- 
ity of  the  eyeball,  the  paralyzed  muscle  acts  to  a  certain  extent  inde- 
pendently of  the  corresponding  one  in  the  other  eye,  and  as  the  globe  is 
extremely  movable,  and  very  slight  force  is  requisite  to  turn  it  in  one  or 
the  other  direction,  the  affected  muscle  may  be  sufficiently  innervated  by 
a  strong  effort  of  the  will  to  perform  the  required  movement.  The  dimi- 
nution of  the  relative  mobility,  however,  becomes  evident  even  when  the 
muscular  paresis  is  very  slight.  When  the  patient  is  directed  to  look  at 
an  object  with  both  eyes  the  movements  of  the  globes  are  always  asso- 
ciated, and  the  innervation  of  the  paralyzed  muscle,  as  well  as  its  corre- 
sponding healthy  fellow,  is  equal,  and  merely  sufficient  to  direct  the  eye 
whose  muscles  are  unaffected  upon  the  object. 

The  paretic  muscle  receives  an  insufficient  amount  of  innervation,  and 
is  therefore  unable  to  carry  the  globe  as  far  as  its  "fellow.  Thus,  if  we 
direct  a  patient  whose  right  external  rectus  is  paralyzed  to  follow  an 
object,  which  we  hold  in  the  hand,  with  both  eyes,  we  will  find  that  when 
the  object  is  held  in  the  right  half  of  the  field  of  vision,  it  is  not  followed 
so  far  by  the  right  eye  as  by  the  left.  Upon  carefully  watching  the  eye 
we  Vrill  also  find  that  the  affected  muscle  appears  to  act  spasmodically, 
imparting  to  the  eyeball  a  vibrating  movement.  In  consequence  of  the 
insufficiency  of  the  paralyzed  muscle,  the  visual  axes  of  the  eyes  do  not 
converge  upon  the  object  which  is  looked  at,  and  double  vision  (diplopia) 
is  therefore  the  result.  This  only  occurs  in  that  part  of  the  field  of  vision 
which  is  dominated  by  the  paralyzed  muscle,  and  it  is  also  found  that  the 
separation  of  the  two  images  becomes  greater,  the  more  the  affected  mus- 
cle is  brought  into  play.  This  is  but  natural,  since  the  continued  move- 
ment of  the  normal  eye  while  the  affected  one  remains  stationary  must 
result  in  an  increase  of  the  divergence  of  the  visual  axes.  When  the 
eyes  are  directed  into  a  portion  of  the  field  of  vision  in  which  the  par- 
alyzed muscle  is  not  called  into  play  the  diplopia  disappears.  There 
is,  therefore,  a  distinct  portion   of  the  field  of  vision  in  which  double 


PERIPHERAL    PARALYSIS.  197 

vision  is  observed  in  paralysis  of  any  of  the  ocular  muscles,  and  a  knowl- 
edge of  this  fact  sometimes  enables  us  to  make  a  diagnosis  of  paresis  of 
a  certain  muscle  when  the  loss  of  power  is  so  slight  that  it  produces  no 
apparent  visible  effect  upon  the  movements  of  the  globe.  The  variations 
in  the  separation  of  the  two  images  can  be  best  studied  by  placing  a 
piece  of  colored  glass  before  one  eye,  thus  enabling  the  patient  to  readily 
differentiate  the  images. 

Very  frequentl}-,  also,  the  head  is  placed  in  a  peculiar  position  in  order 
that  the  patient  may  more  readily  dominate  that  portion  of  the  field  of 
vision  in  which  the  diplopia  is  not  present.  This  position  is  also  very  sig- 
nificant in  making  a  diagnosis. 

Vertigo  is  an  almost  constant  concomitant  symptom  of  double  vision. 
It  was  formerly  supposed  that  this  was  merely  due  to  the  confusion  of 
mind  caused  by  the  presence  of  the  two  images.  J.  Hughlings  Jackson 
believes  that  the  vertigo  from  paralysis  of  ocular  muscles  ''  is  due  to  a 
wrong  estimation  of  the  position  of  external  objects  by  the  one  63*6  whose 
muscle  is  paralyzed."  Thus,  if  the  external  rectus  is  paralyzed,  the  pa- 
tient imagines  that  objects  in  the  outer  part  of  the  field  of  vision  are  sit- 
uated more  to  the  side  than  they  really  are,  and  if  he  attempts  to  seize 
an  object  in  this  position,  he  will  miss  it,  his  hand  passing  to  the  outside. 
This  is  due  to  the  fact  that  in  the  attempt  to  retain  binocular  vision,  the 
paralj'zed  muscle  is  innervated  more  strongly  than  usual,  but  without 
producing  an  equivalent  movement  of  the  globe.  The  position  of  objects, 
however,  is  determined  by  experience  from  the  amount  of  nerve-force 
which  is  expended  in  converging  the  eyes  upon  them,  and  the  patient, 
who  expends  a  large  amount  of  nerve-force  upon  the  paralyzed  muscle, 
therefore  thinks  that  the  object  is  correspondingly  far  removed  from  the 
median  line.  The  apparent  motion  of  surrounding  objects  which  is  due 
to  this  cause  confuses  the  mind  of  the  patient  and  gives  rise  to  vertigo. 
The  correctness  of  this  view  is  substantiated  by  the  fact  that  the  vertigo 
occurring'  in  ocular  paralysis  does  not  disappear  w^hen  the  healthy  eye  is 
closed,  but  only  upon  closure  of  the  affected  one.  After  the  latter  has 
become  accustomed  to  this  condition  the  vertigo  will  disappear  if  the 
healthy  eye  be  kept  continually  closed. 

In  long-standing  paralysis  of  the  ocular  muscles  contracture  of  the 
antagonists  is  very  apt  to  develop  on  account  of  their  unopposed  action. 
This  condition  is  always  followed  by  an  extension  of  that  portion  of  the 
field  of  vision  in  which  the  double  images  are  visible;  it  also  delays  the 
recovery  from  the  paralysis  by  keeping  the  paralyzed  muscle  in  a  contin- 
ual state  of  tension. 

"VYe  shall  consider  separately  the  clinical  history  of  paralysis  of  the 
nerves  distributed  to  the  ocular  muscles,  but  the  remarks  on  etiology  and 
treatment  will  apply  equally  to  all. 


Pakaltsis  of  the  Thikd  Nerve. 

The  third  nerve  (motor  oculi  communis)  is  distributed  to  the  superior, 
inferior,  and  internal  recti,  the  levator  palpebraa  superioris,  inferior  ob- 
lique, the  ciliary  muscle,  and  the  sphincter  of  the  iris.  The  paralysis  may 
involve  these  muscles  separately  or  in  combination.  In  the  latter  event 
the  symptoms  are  very  characteristic.  The  paralysis  of  the  levator  labii 
superioris  gives  rise  to  drooping  of  the  upper  lid  (ptosis),  so  that  the  e3'e 
is  completely  closed,  and  cannot  be  opened  voluntarily.     In  some  cases. 


198  FUNCTIONAL    NERVOUS    DISEASES. 

however,  slight  control  of  the  lid  is  still  manifested,  but  this  appears  to 
be  due  to  forced  contraction  of  the  corrugator  supercilii,  which  pulls  upon 
the  integument,  and  thus  mechanically  draws  the  lid  upward.  This  is 
readily  seen  by  looking  into  a  mirror  and  forcibly  corrugating  the  brow; 
with  each  movement  of  the  brow,  the  upper  lid  will  be  found  to  be 
slightly  raised.  In  complete  paralysis  of  the  muscle  the  patients  fre- 
quently raise  the  lid  with  the  fingers.  The  paralysis  of  the  ocular  muscles 
proper  causes  loss  of  the  power  of  moving  the  globe  in  the  directions 
governed  by  these  muscles.  In  this  case  the  patient  is  only  capable  of 
turning  the  eye  outward  (contraction  of  the  external  rectus),  and  down- 
ward and  outward  (contraction  of  the  superior  oblique).  In  fresh 
cases  the  antero-posterior  axis  of  the  eye  is  situated  in  its  normal  posi- 
tion, but  in  old-standing  cases  contracture  of  the  non-paralyzed  external 
rectus  and  superior  oblique  occurs,  and  the  axis  of  the  eye  is  directed 
outward  and  somewhat  downward.  The  paralysis  of  the  muscles  also 
causes  slight  protrusion  of  the  eyeball,  on  account  of  the  loss  of  the 
tonicity  of  these  muscles,  which  exercises  traction  upon  the  globe,  and 
thus  keeps  it  well  within  the  orbit.  When  ptosis  is  present,  diplopia 
does  not  occur,  as  a  matter  of  course.  But  if  the  levator  palpebree  is  not 
paralyzed,  the  diplopia  becomes  excessively  annoying,  and  is  present  in 
all  parts  of  the  field  of  vision  except  to  the  outside,  and  downward  and 
outside.  The  second  image  is  situated  above  the  first  and  slightly  to  the 
inside,  and  the  distance  between  the  two  increases  as  the  object  ap- 
proaches the  inner  limit  of  the  field  of  vision.  On  account  of  the  number 
of  muscles  paralyzed  the  position  of  all  objects  except  those  situated  to 
the  outside,  and  to  the  outside  and  downward,  is  miscalculated,  and  the 
patients  therefore  suffer  severely  from  vertigo,  so  that  frequently  they 
are  compelled  to  walk  very  slowly. 

The  pupil  is  markedly  dilated  (mydriasis)  on  account  of  the  paralysis 
of  the  sphincter  iridis.  Complete  dilatation  does  not  occur,  and  the  in- 
troduction of  a  solution  of  atropia  into  the  eye  will  cause  the  pupil  to 
dilate  still  further.  The  iris  does  not  contract  to  the  stimulus  of  light, 
since  this  act  is  effected  by  reflex  transmission  of  an  impression  upon  the 
optic  nerve  through  the  motor  oculi  communis.  Distinct  vision  is  there- 
fore interfered  with  to  a  certain  extent,  because  the  dispersion  of  light 
upon  the  retina  is  not  prevented. 

Paralysis  of  the  ciliary  muscle  causes  loss  of  the  power  of  accommo- 
dation. This  muscle  derives  its  nervous  supply  from  the  ophthalmic  or 
ciliary  ganglion,  the  motor  root  of  which  is  furnished  by  a  branch  of  the 
third  nerve.  The  patients  are  unable  to  read  small  print,  and  the  visual 
limit  for  near  objects  is  further  removed  from  the  eye;  vision  is  unaffected 
as  regards  distant  objects. 

As  we  have  mentioned  in  the  chapter  on  etiology,  the  ciliary  muscle 
may  be  the  only  one  affected  in  paralysis  after  diphtheria. 

When  all  these  symptoms  are  combined  it  is  impossible  to  mistake 
their  signification,  but  a  diagnosis  sometimes  becomes  difficult  when  only 
a  single  muscle  is  paretic.  The  character  of  the  diplopia  varies  according 
to  the  muscle  paralyzed.  When  the  internal  rectus  is  affected  the  images 
are  placed  side  by  side,  the  false  image  being  situated  to  the  inside  of 
the  true  one.  When  the  superior  rectus  is  involved  double  vision  is  mani- 
fested in  the  upper  half  of  the  field  of  vision — the  false  image  is  above 
and  to  the  outside  of  the  true  one.  In  paralysis  of  the  inferior  rectus 
these  conditions  are  reversed.  In  paralysis  of  the  inferior  oblique  muscle 
the  false  image  would  be  above  the  true  one,  and  is  slightly  inclined  from 


PERIPHERAL    PARALYSIS.  199 

the  vertical.     It  is  doubtful,  however,  "whether  this  muscle   is  ever  para- 
lyzed separately. 

These  relative  positions  will  vary  somewhat  when  more  than  one  mus- 
cle is  paralyzed,  but  an  accurate  knowledge  of  the  action  of  the  ocular 
muscles  will  enable  us  to  determine  the  presence  of  very  slight  paresis 
from  the  position  of  the  images.  Fortunately,  however,  we  are  rarely 
compelled  to  make  a  diagnosis  in  this  manner,  as  the  attempt  to  move  the 
globe  in  various  directions  will  usually  enable  us  to  detect  the  muscle  at 
fault  by  mere  inspection. 


Pabalysis  of  the  Fourth  Nerve. 

The  fourth  nerve  or  patheticus  is  distributed  to  only  a  single  muscle, 
viz.,  the  superior  oblique.  This  muscle  serves  to  rotate  the  eye  from 
without  inward,  and  from  below  upward,  so  that  the  pupil  is  directed 
downward  and  outward.  Unless  the  paralysis  is  complete,  no  loss  of 
power  in  moving  the  eyeball  will  be  noticeable,  as  the  external  and  infe- 
rior rectus  perform  the  work  of  the  affected  muscle.  The  position  of  the 
double  images  is  therefore  important  in  making  a  diagnosis.  Diplopia 
only  occurs  in  the  lower  half  of  the  field  of  vision;  the  images  are  situ- 
ated one  above  the  other,  the  false  image  being  below  the  true  one,  and 
situated  obliquely  so  that  its  lower  end  deviates  to  the  outside.  The 
head  is  usually  inclined  forward  in  order  to  bring  objects  into  the  upper 
half  of  the  field  of  vision,  and  thus  avoid  the  development  of  double  im- 
ages as  far  as  possible. 


Paralysis  of  the  Sixth  Nerve. 

Like  the  fourth  nerve,  the  sixth  or  motor  oculi  externus  is  also  distrib- 
uted to  a  single  muscle,  viz.,  the  external  rectus.  This  muscle  merely 
revolves  the  globe  outward,  and  the  effects  of  its  paralysis  are  very  sim- 
ple. Convergent  squint  is  observed  from  the  unopposed  action  of  the  in- 
ternal rectus,  and  the  eye  cannot  be  turned  outward. 

"When  the  paralysis  is  slight,  strabismus  is  not  present,  and  the  di- 
minished power  of  the  muscle  may  only  become  apparent  when  an  object 
is  brought  close  to  the  eye.  On  account  of  the  paresis  of  the  external 
rectus,  its  opponent  contracts  too  strongly,  and  the  eye  is  therefore  re- 
volved inward.  Diplopia  occurs  in  the  outer  half  of  the  field  of  vision, 
the  false  image  being  situated  to  the  outside  of  the  true  one,  and  the  dis- 
tance between  them  increasing  as  the  objects  approach  the  outer  limits  of 
the  field  of  vision.  The  patient  therefore  imagines  objects  to  be  situated 
to  the  outside  of  their  true  position. 


Etiology. 

In  my  own  experience  paralysis  of  the  ocular  muscles  belongs  to  the 
more  uncommon  varieties  of  paralysis,  but  this  is  probably  owing  to  the 
fact  that  the  attention  of  patients  is  often  attracted  at  first  by  the  diplo- 
pia, and  an  ophthalmologist  is  therefore  consulted.  The  trochlearis  nerve 
is  involved  much  less  frequently  than  either  of  the  others.  In  paralysis 
of  the  motor  oculi  communis   only  one  or  two  branches  of  the  nerve  are 


200  FUNCTIONAL    NERVOUS   DISEASES. 

usually  affected,  the  entire  nerve  being  less  often  involved;  ptosis  is  fre- 
quently the  only  symptom  observed.  The  paralysis  may  also  affect  more 
than  one  of  the  nerves,  and  sometimes  various  nerves  of  both  eyes  suffer 
at  the  same  time  or  in  succession. 

The  affection  is  most  frequently  due  to  rheumatic  causes,  such  as  ex- 
posure, etc.  Patients  are,  however,  very  apt  to  attribute  the  paralysis  to 
"  catching  cold,"  although  no  definite  exposure  can  be   mentioned. 

A  considerable  contingent  of  the  cases  is  due  to  syphilis,  which  prob- 
ably gives  rise  more  frequently  to  parah'sis  of  the  ocular  muscles  than  of 
any  other  ;  ptosis  often  develops  from  this  cause.  Syphilis  may  produce 
lesions  of  the  motor  nerves  of  the  eye  either  wuthin  the  orbit  or  in  the 
cranial  cavity.  In  either  of  these  situations  it  may  cause  pressure  upon 
the  nerves  from  the  development  of  periostitis,  exostoses  or  gummatous 
growths  growing  from  the  nerves  or  from  adjacent  tissues.  AVithin  the 
cranial  cavity  it  may  also  cause  pressure  upon  the  nerves  by  producing 
pachymeningitis  or  basilar  meningitis  wdth  subsequent  retraction  of  the 
tissues.  These  paralyses,  as  is  evident  from  the  nature  of  the  lesion, 
occur  during  the  tertiary  stage  of  syphilis. 

A  certain  proportion  of  ocular  paralyses  are  due  to  various  forms  of 
traumatism,  such  as  fracture  of  the  skull  in  its  anterior  portions,  hemor- 
rhages into  the  orbit,  direct  wounds  with  a  knife  or  other  instrument, 
blows  with  the  fist,  etc.  A  knowledge  of  the  clinical  history  is  always 
sufficient  to  enable  us  to  form  a  correct  appreciation  of  such  cases. 

Diphtheria  and  typhoid  fever  may  also  be  followed  by  ocular  paralysis, 
the  former  often  giving  rise  to  uncomplicated  paralysis  of  the  ciliary 
muscle  (loss  of  the  power  of  accommodation). 

Knapp  has  reported  a  case  of  paralysis  of  all  the  ocular  muscles  due 
to  coal-gas  poisoning  ;  this  may  also  be  produced  by  chronic  opium- 
poisoning. 

Various  intracranial  lesions  may  give  rise  to  the  affection,  viz.,  basilar 
meningitis,  periostitis,  and  exostoses,  tumors  growing  from  the  base  of 
the  skull,  aneurisms  of  the  internal  carotids.  In  some  cases  tumors  of 
the  parenchyma  of  the  anterior  portion  of  the  brain  may  produce  peri- 
pheral paralysis  of  the  motor  nerves  of  the  eye  by  growing  downward 
and  thus  causing  pressure  upon  the  nerves  between  their  exit  from  the 
brain  and  their  entrance  into  the  sphenoidal  fissure.  Tumors  of  the 
crura  cerebri  and  pons  are  also  very  apt  to  produce  pressure  on  these 
nerves. 


DiAG^rosis  AND  Prognosis. 

In  complete  paralysis  of  all  the  branches  of  one  of  the  nerves  the  ap- 
pearances presented  are  sufficiently  characteristic  to  enable  a  diagnosis 
to  be  made  by  mere  inspection,  except  in  paralysis  of  the  trochlearis. 
In  this  case,  and  especially  when  the  paralysis  is  very  slight,  the  diagnosis 
can  only  be  made  with  certainty  after  a  careful  study  of  the  relative  posi- 
tions of  the  double  images,  as  we  have  shown  in  the  remarks  on  the  pre- 
ceding page.  In  doubtful  cases  of  paresis  of  the  other  nerves  this 
method  should  also  be  adopted. 

The  mode  of  development  of  the  paral^'sis  will  usually  enable  us  to 
determine  its  causation.  It  may  be  difficult,  however,  to  ascertain  the 
character  of  the  lesion  when  it  is  intracranial  in  its  origin. 

In  lesions  of  the  base  of  the  brain  other  cerebral  nerves,  such  as  the 


PERIPHEEAL   PAPwALTSIS.  201 

fifth  and  seventh,  are  apt  to  be  implicated,  optic  neuritis  often  develops, 
there  is  persistent  headache,  and  paralysis  of  the  limbs  does  not  occur 
until  a  later  period.  When  the  paralysis  is  due  to  the  presence  of  tumors 
growing  in  the  crus  cerebri,  hemiplegia  of  motion  and  sensation  occurs, 
the  paralysis  of  the  motor  oculi  communis  occurs  on  the  side  opposite  to 
that  of  the  body,  and  at  a  later  period  the  opposite  third  nerve  also  be- 
comes affected. 

Temporary  paralysis  of  the  ocular  muscles  may  occur  in  the  early 
stages  of  locomotor  ataxia,  and  it  is  very  important  that  its  character 
should  be  recognized.  In  such  cases  careful  questioning  will  usually 
show  that  the  patient  has  previously  suffered  from  lancinating  pains 
in  the  legs,  that  he  finds  a  little  difficulty  in  walking  in  the  dark,  and 
that  there  is  some  numbness  in  the  soles  of  the  feet.  The  absence  of  the 
tendon-reflex,  as  we  have  shown  previously,  is  also  an  important  diagnos- 
tic sign.  In  addition,  one  of  the  pupils  may  be  contracted  almost  to  a  pin- 
point; atrophy  of  the  optic  nerves  is  also  noticed  at  times  in  the  very 
beginning  of  the  disease. 

The  prognosis  varies  with  the  nature  of  the  cause.  Those  varieties 
which  are  due  to  syphilis  are  usually  curable  under  appropriate  treatment, 
but  relapses  are  not  infrequent.  Rheumatic  cases  of  recent  date  also 
present  a  favorable  prognosis,  but  the  chances  of  recovery  diminish  the 
longer  the  j^aralysis  has  lasted;  this  is  especially  true  of  those  cases  in 
which  contracture  of  the  antagonistic  muscles  has  occurred. 

The  paralyses  developing  after  diphtheria  and  typhoid  fever  present 
an  excellent  prognosis,  and  recovery  often  occurs  spontaneously. 

When  the  affection  is  due  to  traumatism,  hemorrhage,  etc.,  the  prog- 
nosis depends  upon  the  amount  of  injury  which  the  nerve  has  sustained, 
and  varies  therefore  in  each  individual  case.  Those  forms  which  are 
symptomatic  of  tumors  at  the  base  of  the  brain  are,  of  course,  hopeless. 


Treatment. 

The  main  reliance  must  be  placed  on  the  prolonged  use  of  electricity; 
it  is  immaterial  which  form  is  employed,  some  writers  preferring  the 
faradic,  others  the  galvanic  current.  One  electrode  should  be  placed 
upon  the  corresponding  mastoid  process  or  upon  the  temple,  and  the  other 
(with  a  small,  olive-shaped  tip)  upon  that  portion  of  the  closed  lid  whicTi 
is  nearest  to  the  insertion  of  the  paralyzed  muscle.  The  ocular  electrode 
is  also  applied,  at  times,  directly  upon  the  sclerotic  coat,  close  to  the  in- 
sertion of  the  affected  muscle.  This  method  is  often  annoying  to  the 
patient,  and  its  advantages  do  not  counterbalance  its  inconveniences.  But 
with  either  method  of  application  the  current  employed  should  be  very 
mild  and  never  sufficiently  intense  to  give  rise  to  pain.  Not  infrequently 
a  single  application  of  electricity  will  suffice  to  produce  a  decided  and 
permanent  improvement  in  the  power  of  the  muscles.  It  would  seem,  in 
fact,  as  if  the  passage  of  the  electrical  current  through  the  nerves  renders 
the  passage  of  the  stimulus  of  the  will  more  easy. 

In  paralysis  of  the  levator  palpebrte  superioris,  the  ptosis  may  be 
overcome  and  the  passive  elongation  of  the  muscle  relieved  at  the  same 
time  by  the  application  of  a  small  bit  of  rubber  which  is  fastened  to  the 
upper  lid  and  forehead  by  means  of  a  couple  of  pieces  of  adhesive  plaster. 

The  use  of  prisms,  in  order  to  avoid  the  development  of  double  images, 


202  FUXCTIOl^AL    NERVOUS    DISEASES. 

is  not  to  be  recommended,  as  the  separation  of  the  latter  varies  with  the 
part  of  the  field  of  vision  in  which  the  object  is  situated.  In  the  second- 
ary contracture  of  the  antagonist  muscles,  resort  must  often  be  had  to 
suro-ical  measures,  viz.,  section  of  the  contractured  muscles. 

In  those  forms  which  are  due  to  periostitis  of  the  bones  of  the  base  of 
the  skull,  or  to  basilar  meningitis,  some  benefit  may  perhaps  be  obtained 
by  the  long-continued  administration  of  iodide  of  potassium,  and  the  ap- 
plication of  counter-irritation  to  the  nape  of  the  neck.  In  tumors  of  the 
brain,  unless  of  a  specific  nature,  treatment  is  of  no  avail. 


CHAPTER  V. 

PARALYSIS  OF  THE  NERVE  OF  MASTICATION. 

(Motor  Root  of  the  Fifth.) 

Clinical  Histoby. 

This  nerve  is  distributed  to  the  muscles  of  mastication  (temporal,  mas- 
seter,  internal  and  external  pterygoid,  mylohyoid  and  digastric),  and  to  the 
tensor  veli  palati;  it  also  sends  filaments  to  the  buccinator,  but  these  are 
purely  sensory  in  character,  the  muscle  deriving  its  motor  supply  from 
the  facial  nerve.  The  symptoms  of  paralysis  of  the  nerve  of  mastication 
are  well  shown  in  the  following  case  which  came  under  my  observation, 
although  it  was  complicated  by  a  lesion  of  the  sensory  branches  of  the 
trigeminus,  and  the  symptoms  of  the  latter  are  therefore  superadded. 

Case  V, — M.  E.,  set.  45  years,  married;  no  history  of  specific  disease;  a 
moderate  drinker.  The  patient  had  remittent  fever  six  years  ago,  and 
has  had  chills  from  time  to  time  ever  since.  Three  years  ago  he  began  to 
suffer  from  pain  in  the  right  temple  and  the  right  side  of  the  face;  the 
pain  extended  to  the  crown  of  the  head,  and  was  very  intense  from  the 
beginning.  For  a  period  of  six  months  the  pain  was  continuous,  but 
since  then,  although  the  patient  has  pain  every  day,  it  comes  on  in  par- 
oxysms lasting  three  or  four  minutes,  and  then  disappears  for  the  rest 
of  the  day.  About  a  year  ago,  numbness  began  to  appear  in  the  painful 
spots  and  obtained  its  greatest  intensity  a  week  afterward;  this  has  per- 
sisted ever  since.  There  has  been  at  times  a  slight  purulent  discharge 
from  the  right  ear,  and  the  patient  feels  easier  when  this  is  running;  he 
has  not  tasted  anything  on  the  right  side  of  the  tongue  since  the  anaes- 
thesia appeared  in  the  face. 

Present  condition. — There  is  a  depression  over  the  right  temple  due  to 
atrophy  of  the  temporal  muscle.  AH  the  superficial  facial  muscles  on 
this  side  act  apparently  as  well  as  on  the  other.  There  is  almost  com- 
plete anaesthesia  on  this  side,  the  anaesthetic  zone  being  bounded  ante- 
riorly by  the  median  line,  posteriorly  by  a  line  drawn  from  the  front  of  the 
ear  to  the  vertex,  and  below  by  a  line  from  the  front  of  the  ear  to  the 
chin,  this  boundary  running  a  little  above  the  lower  border  of  the  jaw. 
The  integument  on  the  right  side  of  the  nose,  right  upper  lip,  and  half  of 
the  cheek  adjoining  is  hard,  stiff,  thickened,  and  shining.  The  right  ala 
nasi  is  drawn  upward,  thus  enlarging  the  nostril,  which  bleeds  readily 
when  pricked  ;  the  patient  cannot  taste  anything  on  the  anterior  half  of 
the  right  side  of  the  tongue. 

The  right  lower  teeth  cannot  be  carried  forward  by  the  patient  to  a  line 
with  the  upper  row  on  the  right  side.  When  an  attempt  is  made  to  per- 
form this  movement,  the  lower  jaw  projects  further  forward  on  the  left 


204  FUNCTIONAL   NERVOUS   DISEASES. 

side  than  it  does  on  the  right,  moving  apparently  as  if  turned  on  a  pivot 
around  the  right  temporo-maxillary  articulation.  The  jaws  cannot  be 
brought  firmly  against  one  another  on  the  right  side,  and  the  food  cannot 
be  chewed  on  this  side.  There  is  no  paralysis  of  the  palate  or  uvula. 
I  am  sorry  to  state  that  the  electrical  reactions  of  the  paralyzed  muscles 
■were  not  taken,  as  I  only  saw  the  patient  once,  and  he  then  passed  out  of 
my  observation. 

The  symptoms  of  this  case  are  readily  explained  by  pressure  upon  the 
trunk  of  the  trigeminus,  including  the  sensory  as  well  as  the  motor 
branches  (probably  from  periostitis  of  the  petrous  portion  of  the  tempo- 
ral bone).  Pressure  upon  the  former  accounts  for  the  neuralgic  pain,  the 
anjEsthesia  and  trophic  disturbances,  w^hile  pressure  upon  the  latter  ex- 
plains the  motor  disorders.' 

Paralysis  of  the  motor  root  of  the  trigeminus  is  usually  unilateral,  as 
in  the  above-mentioned  case,  but  it  is  bilateral  in  rare  instances.  The 
motor  symptoms  described  above  follow  naturally  from  the  loss  of  power 
in  the  muscles  of  mastication.  The  masseter,  temporal,  and  the  two 
pterygoids  combine  in  the  act  of  raising  the  lower  jaw,  and  their  paraly- 
sis of  course  abolishes  this  mavement  on  the  affected  side.  Depression 
of  the  jaw  is  chiefly  effected  by  the  action  of  the  digastric  and  mylohyoid 
muscles,  but  their  unilateral  paralysis  is  insufficient  to  prevent  this  move- 
ment, as  the  corresponding  muscles  on  the  opposite  side  contract  with 
sufficient  vigor  to  produce  depression  ;  in  bilateral  paralysis,  however, 
this  movement  is  also  abolished.  Lateral  movements  are  effected  by  the 
alternate  action  of  the  pterygoids  and  the  anterior  fibres  of  the  temporal 
and  masseter  ;  these  actions  are  also  abolished  in  this  form  of  paralysis, 
and  the  contraction  of  the  corresponding  healthy  muscles  on  the  opposite 
side  give  rise  to  the  peculiar  movements  which  have  been  described 
above.  As  we  have  previously  mentioned,  the  nerve  also  sends  filaments 
to  the  tensor  veli  palati,  but  paralysis  of  this  muscle  has  not  been 
hitherto  observed  in  this  affection. 

All  the  various  changes  in  electrical  reactions  which  we  have  described 
as  occurring  in  peripheral  paralysis,  have  been  occasionally  noticed  in  the 
affected  muscles  in  this  disease  ;  very  little  attention  has  been  devoted, 
however,  to  these  symptoms.  Atrophy  of  the  muscles  usually  occurs, 
and  that  of  the  temporals  can  be  readily  seen  upon  inspection  ;  the 
prominence  in  the  temporal  fossa  diminishes,  and  a  well-marked  depres- 
sion may  even  become  visible. 

Atrophy  of  the  masseter  is  also  readily  recognized  by  placing  one 
finger  in  the  mouth  and  another  upon  the  cheek  over  the  position  of 
this  muscle,  and  then  making  a  comparison  between  the  two  sides. 

When  the  motor  trigeminal  root  is  alone  paral3'zed,  the  symptoms 
are  restricted  to  those  which  we  have  just  described,  but  some  of  the 
other  cranial  nerves,  especially  the  sensory  branches  of  the  fifth,  are 
generally  implicated  at  the  same  time.  The  symptoms  are  then  compli- 
cated with  those  due  to  the  concomitant  affections. 

'  This  case  is  also  interesting  from  a  physiological  standpoint,  as  it  tends  to  show 
that  the  chorda  tympani,  which  supplies  the  anterior  half  of  the  tongue  with  the 
sense  of  taste,  makes  its  exit  from  the  brain  in  the  course  of  the  trigeminus,  as  taste 
was  abolished  in  the  distribution  of  the  chorda  tympani,  although  the  lesion  was  un- 
doubtedly situated  in  the  intra-cranial  portion  of  the  trigeminus,  and  there  was  no 
peripheral  lesion  of  the  seventh  nerve,  through  which  the  chorda  tympani  passes  during 
a  part  of  its  course. 


PERIPHERAL   PARALYSIS.  205 


Etiology. 

This  disease  is  exceedingly  rare,  especially  as  a  peripheral  affection, 
but  it  is  occasionally  met  with  in  alfections  of  the  pons  varolii  and 
medulla  oblongata. 

The  peripheral  causes  which  give  rise  to  it  are  also  usually  intra- 
cranial, and  include  periostitis  and  exostoses  of  the  bones  at  the  base  of 
the  skull,  especially  the  petrous  portion  of  the  temporal,  aneurisms  of 
the  arteries  at  the  base  of  the  brain,  and  tumors  growing  in  this  reo-ion. 
Paralysis  of  this  nerve  from  a  lesion  involving  its  extra-cranial  course 
must  be  extremely  rare,  as  I  have  not  met  with  any  reported  cases  of 
this  character.  This  circumstance  is  due  to  the  deep-seated  position 
which  the  nerve  occupies  after  its  exit  from  the  cranial  cavity. 


Diagnosis  and  Prognosis. 

This  affection  is  not  readily  mistaken  for  any  other,  unless  a  very 
careless  examination  is  made.  The  patient  usually  complains  voluntarily 
of  the  disturbance  in  the  process  of  mastication,  and  inspection  of  the 
parts  shows  that  the  corresponding  muscles  are  incapable  of  performinc 
their  functions.  The  peculiar  position  of  the  lower  jaw  when  the  patient 
is  directed  to  move  it  from  side  to  side  or  antero-posteriorly,  is  a  pathog- 
nomonic sign. 

The  prognosis  as  regards  recovery  from  the  paralysis  is  bad  in  all 
cases  ;  the  prognosis  as  regards  life  depends  upon  the  character  of  the 
primary  lesion,  whether  it  is  continually  progressive,  like  a  tumor  or 
aneurism,  or  whether  its  further  progress  may  cease,  like  that  of  an 
exostosis  or  periostitis. 


Treatment. 

Very  little  can  be  done  in  this  direction.  "When  we  suspect  that  the 
disease  is  due  to  periostitis  of  the  temporal  bone,  some  benefit  may 
perhaps  be  derived  from  counter-irritation  over  the  mastoid  process,  and 
the  internal  administration  of  iodide  of  potassium.  The  employment  of 
electricity  has  also  been  advised,  that  current  being  employed  to  which 
the  muscles  respond  most  readily.  The  current  must  be  applied  directly 
to  the  muscles,  as  the  nerve  is  so  deeply  situated  that  it  is  not  easily 
reached. 


CHAPTER  YI. 

FACIAL   PARALYSIS. 

Clinical  History. 

Facial  paralysis  *  is  one  of  the  most  interesting,  as  well  as  the  most 
frequent  of  all  forms  of  peripheral  paralysis.  It  is  unilateral  in  the  large 
majority  of  cases,  but  in  exceptional  instances  it  affects  both  seventh 
nerves,  and  is  then  sometimes  known  as  diplegia  facialis.  It  may  develop 
suddenly,  as  when  the  paralysis  immediately  follows  exposure  to  a  draught,, 
or  occurs  very  gradually,  as  in  some  cases  which  are  due  to  pressure  on 
the  nerve  from  a  slowly  growing  tumor,  etc.  At  the  onset  of  the  disease, 
the  patients,  being  misled  by  the  appearance  of  the  parts,  often  believe 
that  the  face  is  swollen,  and  are  astonished  upon  being  informed  of  the 
true  condition.  When  the  paralysis  is  complete,  the  appearances  pre- 
sented are  very  characteristic,  and  cannot  be  mistaken  for  any  other  con- 
dition. The  wrinkles  in  the  forehead  on  the  paralyzed  side  disappear,  the 
eye  is  widely  open  and  staring,  the  naso-labiai  fold  is  effaced,  the  ala 
nasi  is  in  closer  approximation  to  the  septum  of  the  nose  than  on  the 
healthy  side,  the  angle  of  the  mouth  droops  and  is  nearer  to  the  median 
line  than  normal.  The  contrast  between  the  paralyzed  and  healthy  sides 
of  the  face  becomes  much  more  marked  when  the  patient  attempts  to 
perform  voluntary  facial  movements.  The  paralyzed  side  then  remains 
motionless,  like  a  mask,  and  the  healthy  side  becomes  distorted,  as  those 
muscles  which  are  inserted  into  the  angle  of  the  mouth  draw  it  over  to 
the  normal  side  because- they  are  unopposed  by  their  antagonists.  The 
eye  remains  widely  open  during  sleep  as  well  as  in  the  waking  condition. 
When  the  patient  makes  a  vigorous  effort  to  close  the  lids  the  eyeball  is 
rolled  upward  and  slightly  inward  until  the  lower  border  of  the  cornea  is 

'  After  emerging  from  the  lateral  tract  of  the  medulla  oblongata  at  the  lower  bor- 
der of  the  pons  varolii,  the  seventh  nerve  passes  into  the  internal  auditory  canal,  and 
then  through  the  Fallopian  canal.  It  emerges  at  the  stylo-mastoid  foramen,  im- 
mediately beneath  the  lobe  of  the  ear,  passes  downward  and  then  forward  to  spread 
over  the  surface  of  the  face.  At  the  first  bend  (genu)  which  the  nerve  makes  in  the 
Fallopian  canal  is  situated  a  gangliforra  enlargement  known  as  the  ganglion  genicula- 
tum.  I'rom  this  enlargement  emerges  the  petrosus  superficialis  major  nerve  which 
goes  forward  to  enter  the  nasal  ganglion,  after  which  it  passes  downward  to  supply 
the  levator  palati,  and  perhaps  other_  muscles  of  the  velum  palati  and  uvula.  It  is 
also  supposed  that  the  fibres  of  the  chorda  tympani  pass  through  the  petrosus  super- 
ficialis major  to  enter  the  ganglion  geniculatum,  after  which  they  pursue  the  same 
course  as  the  other  fibres  of  the  seventh.  The  next  motor-branch  is  a  small  twig  which 
supplies  the  stapedius  muscle.  Then  the  chorda  tympani  is  given  off  and  joins  the 
lingual  branch  of  the  trigeminus  ;  it  is  the  nerve  of  taste  which  supplies  the  anterior 
third  or  half  of  the  tongue.  At  the  exit  of  the  nerve  from  the  stylo-mastoid  foramen, 
it  gives  off  the  posterior  auricular  branch,  which  supplies  the  muscles  of  the  ear.  The 
nerve  then  divides  into  its  terminal  branches,  which  supply  all  the  muscles  of  expres- 
Bion  and  one  muscle  of  mastication,  viz. :  the  buccinator ;  it  also  sends  filaments  to 
the  stylo-hyoid,  digastric  and  stylo -glossus  muscles. 


PERIPHERAL    PARALYSIS.  207 

on  a  level  with  the  upper  lid.  During  this  attempt  the  upper  lid  also 
becomes  slightly  lowered,  but  the  mechanism  of  this  action  is  not  clearly 
understood;  it  has  been  supposed  that  the  levator  palpebrai  superioris, 
the  unopposed  action  of  which  causes  the  lids  to  be  continually  open,  be- 
comes relaxed  during  the  effort  to  close  the  eye.  Epiphora,  or  overflow 
of  tears,  is  a  constant  symptom  in  this  condition.  This  is  due  to  the  fact 
that  on  account  of  the  paralysis  of  the  lower  segment  of  the  orbicularis 
palpebra?rum,  especially  that  portion  known  as  Horner's  muscle,  the 
lower  lachrymal  point  is  not  kept  applied  against  the  eyeball,  and  the 
tears  are  not  able,  therefore,  to  escape  by  the  usual  channel;  overflow 
then  occurs  as  a  natural  consequence.  On  account  of  the  exposed  con- 
dition of  the  globe  of  the  eye,  and  the  inability  to  wash  away  foreign 
particles  by  the  act  of  winking,  a  certain  amount  of  conjunctival  irrita- 
tion is  usually  present,  unless  precautions  are  adopted  to  shield  the 
eye.  A  few  cases  have  been  reported  in  which  opacity  and  ulceration 
of  the  cornea,  etc.,  occurred,  as  in  cases  of  severe  disease  of  the  trigemi- 
nus, but  it  is  extremely  questionable  whether  these  symptoms  were  the 
result  of  facial  paralysis.  The  speech  of  the  patient  is  indistinct  on  ac- 
count of  his  inability  to  close  the  lips  properly;  the  imperfection  is 
therefore  chiefly  noticeable  in  the  pronunciation  of  labials.  He  is  also 
unable  to  whistle,  purse  the  lips,  etc.,  and,  in  infants,  suckling  is  inter- 
fered with;  when  an  attempt  is  made  to  distend  the  cheeks  the  air  es- 
capes through  the  unclosed  angle  of  the  mouth  on  the  paralyzed  side, 
and  the  cheek  flaps  as  if  it  were  perfectly  limp.  One  of  the  muscles  of 
mastication,  viz. :  the  buccinator,  is  also  supplied  by  the  facial,  and  its 
paralysis  therefore  interferes  to  a  certain  extent  with  this  function.  The 
flaccid  condition  of  this  muscle  prevents  the  cheek  from  being  closely  ap- 
plied against  the  teeth  and  alveolar  processes,  and  particles  of  food,  there- 
fore, slip  in  between  the  teeth  and  cheek  and  must  often  be  removed  from 
this  position  by  the  aid  of  the  finger. 

Some  observers  state  that  the  tongue  deviates  to  one  side  when  pro- 
truded, but  this  statement  is  based  on  an  error  of  observation.  The  angle 
of  the  mouth  on  the  paralyzed  side  is  nearer  to  the  median  line  than  on 
the  sound  side,  and  the  tip  of  the  tongue  therefore  approaches  the  for- 
mer. The  absence  of  deviation  of  the  tongue  is  one  of  the  differential 
signs  between  peripheral  and  cerebral  facial  paralysis. 

In  the  majority  of  cases,  the  uvula  and  velum  palati  are  not  involved, 
but  exceptionally  they  are  also  paralyzed  on  the  affected  side.  The  para- 
lyzed half  of  the  velum  hangs  lower  than  on  the  healthy  side,  and  does 
not  contract  so  readily  during  phonation;  its  reflex  excitability  is  also 
impaired  and  may  be  entirely  wanting.  When  the  azygos  uvuloe  muscle 
is  affected,  deviation  of  the  uvula  occurs;  the  tip  has  been  found  de- 
flected sometimes  toward  the  paralyzed,  sometimes  toward  the  healthy 
side.  But  certain  sources  of  error  should  be  excluded  before  making  a 
diagnosis  of  paralysis  of  the  uvula  and  velum  palati.  In  the  first  place, 
one  pillar  of  the  fauces  may  normally  hang  lower  than  its  fellow,  and 
thus  simulate  paralysis;  but,  in  such  a  case,  its  curve  is  found  to  be 
sharply  defined,  and  upon  irritating  the  fauces  with  any  foreign  substance, 
it  will  draw  up  as  forcibly  as  the  opposite  one.  The  uvula  also  is  not 
unfrequently  deflected  in  health;  in  some  cases,  also,  when  it  is  long  and 
pendulous,  as  after  any  pharyngeal  inflammation,  it  will  topple  over  to- 
ward that  side  to  which  the  face  happens  to  be  turned,  and  may  thus  simu- 
late paralysis.  I  saw  this  mistake  made  by  a  distinguished  physician  of 
this  city,  in  a  case  in  which  the  prognosis  depended  very  considerably  upon 


208  FUNCTIONAL    TirERYOUS    DISEASES. 

the  occurrence  of  this  symptom,  as  indicative  of  the  peripheral  nature 
of  the  affection.  Paralysis  of  the  velum  palati  is  supposed  to  be  due  to 
implication  of  the  nervus  petrosus  superficialis  major,  vphich  passes  from 
the  sranglion  geniculatum  of  the  seventh  nerve  to  the  spheno-palatine  or 
Meckel's  ganglion,  and  thence  to  the  levator  palati  and  probably  other 
muscles  of  the  velum  palati.  But  this  question  in  physiology  is  still  not 
definitely  settled. 

The  special  senses  may  also  be  affected  as  the  result  of  this  dis- 
ease. Thus,  the  sense  of  smell  is  very  often  less  acute  in  the  nostril  of 
the  paralyzed  side,  though  this  is  not  due  to  any  specific  influence  of  the 
seventh  nerve  upon  the  function  of  smell;  its  causes  are  purely  mechani- 
cal. In  the  first  place,  the  cessation  of  the  respiratory  movements  of  the 
ala  nasi  and  the  closer  application  of  the  ala  to  the  septum  of  the  nose, 
prevents  the  introduction  of  the  proper  quantity  of  air,  and  therefore  of 
a  sufficient  number  of  odoriferous  particles.  Furthermore,  the  paralysis 
of  the  orbicularis  palpebrarum  and  the  consequent  epiphora  result  in  an 
insufficient  flow  of  tears  through  the  nasal  duct,  and  then  over  the 
Schneiderian  membrane.  The  latter  therefore  becomes  dry  and  the  ter- 
minal filaments  of  the  olfactory  nerve  are,  accordingly,  not  in  the  proper 
condition  to  receive  odoriferous  impressions. 

The  sense  of  taste  is  also  impaired,  at  times,  and  the  majority  of 
authors  agree  in  the  statement  that  this  symptom  is  quite  rare.  My  own 
experience  has  been  different,  and  I  have  found,  after  examining  a  con- 
siderable number  of  patients,  that  a  certain  diminution  in  the  sense  of 
taste  is  present  in  quite  a  large  proportion  of  cases  taken  indiscriminate- 
1}^  Upon  testing  with  various  sapid  substances,  a  diminution  in  the 
sense  of  taste  will  be  noticed  on  the  anterior  third  of  the  tongue  on  the 
affected  side.  This  examination  must  be  conducted  carefully,  as  the 
patients  are  apt  to  give  misleading  statements.  In  more  exceptional 
cases,  they  state  that  they  have  various  curious  subjective  sensations  of 
taste  in  the  above-mentioned  portion  of  the  tongue.  All  the  symptoms 
are  due  to  an  implication  of  the  chorda  tympani  (which  is  contained  in  the 
trunk  of  the  seventh  nerve  during  a  part  of  its  course)  in  the  primary  lesion. 

The  sense  of  hearing  sometimes  presents  peculiar  disturbances.  We 
do  not  now  refer  to  those  cases  in  which  the  paralysis  is  secondary  to  a 
disease  of  the  ear,  and  in  which  the  auditory  phenomena  are  merely  symp- 
tomatic of  an  organic  affection.  The  phenomena  in  question  consist  of 
a  disagreeable  sensation  within  the  ear,  which  is  experienced  whenever 
the  patient  hears  sounds  of  any  considerable  intensity;  auditory  hyperass- 
thesia  is  also  present,  and  is  characterized  by  an  increased  perception  of 
very  high  and  very  low  notes.  These  symptoms  were  first  noticed  by 
Roux  upon  himself,  while  suffering  from  facial  paralysis,  and  have  been 
since  confirmed  by  other  observers.  Wolff  has  applied  to  this  condition 
the  term  oxyokoia. 

These  symptoms  are  attributed  to  paralysis  of  the  stapedius  muscle, 
which  is  supplied  by  a  small  twig  passing  off  from  the  facial  nerve  during 
its  course  through  the  Fallopian  canal;  the  paralysis  of  this  muscle  causes 
increased  tension  of  the  membrana  tympani  on  account  of  the  unopposed 
action  of  the  tensor  tympani. 

The  secretion  of  saliva  on  the  affected  side  is  usually  diminished,  and 
the  mucous  membrane  of  the  mouth  is  therefore  drier  than  on  the  oppo- 
site side.  Physiological  experiments  have  rendered  it  probable  that  the 
chorda  tympani  nerve  sends  secretory  fibres  to  the  submaxillary  and  sub- 
lingual glands,  and  it  is  supposed  that  the  irritation  of  these  fibres  causes 


PERIPIIERAL   PARALYSIS.  209 

a  diminution  of  the  salivary  secretion.  There  is  no  doubt,  however,  that 
the  increased  dryness  of  the  mouth  on  the  affected  side  is  partly  due  to 
the  fact  that  the  mouth  cannot  be  completely  closed  upon  that  side,  and 
that  the  consequent  exposure  to  the  air  causes  an  increased  evaporation 
of  fluid. 

The  electrical  reactions  of  the  paralyzed  muscles  vary  according  to  the 
severity  of  the  paralysis.  It  was  in  this  affection  that  the  degeneration 
reaction  was  first  observed  by  Baierlacher.  In  the  most  severe  cases  the 
irritability  of  the  nerves  rapidly  diminishes  after  a  few  days,  and  is  soon 
entirely  lost  to  both  the  faradic  and  galvanic  currents  (in  some  cases  it  is 
slightly  increased  for  the  first  few  days).  Within  a  few  days  the  farado- 
muscular  excitability  begins  to  diminish,  grows  gradually  less,  and  within 
two  or  three  weeks  has  entirely  disappeared.  The  galvano-muscular  ex- 
citability is  undisturbed  for  the  first  few  days,  and  then  begins  to  increase 
so  that  finally  the  muscles  react  to  a  very  mild  current.  The  difference 
between  the  contractions  of  the  healthy  and  paralyzed  muscles  can  be  very 
beautifully  shown  in  this  affection.  If  one  electrode  is  placed  at  some  in- 
different spot,  such  as  the  nape  of  the  neck,  and  the  other  over  the  median 
line,  upon  the  forehead  or  chin,  so  that  the  electrode  covers  muscles  on 
both  sides  of  the  face,  and  a  mild  current  is  allowed  to  pass,  it  will  be 
found  that  the  healthy  muscles  remain  quiet  while  the  paralyzed  ones 
contract  vigorously. 

Thus,  the  affected  muscles  may  react  to  two  cells  although  it  re- 
quires ten  or  twelve  to  produce  any  response  from  the  healthy  ones. 
After  a  variable  duration  of  the  degeneration-reaction,  lasting  from  a  few 
weeks  to  several  months,  it  usually  begins  to  disappear,  and  as  the  nor- 
mal galvanic  reactions  reappear,  the  farado-muscular  contractility  also 
redevelops,  and  increases  until  recovery  occurs.  The  irritability  of  the 
nerves  now  also  reappears,  first  to  the  galvanic  and  later  to  the  fara- 
dic current.  Cases  of  this  character  usually  last  at  least  six  months,  and 
often  as  long  as  a  year,  or  even  more.  It  is  also  not  very  infrequent  to 
find  that  voluntary  power  is  completely  restored,  although  the  electrical 
irritability  of  the  nerves  and  muscles  is  still  below  the  normal. 

As  the  severity  of  the  paralysis  varies,  in  different  cases,  we  may  no- 
tice all  the  various  forms  of  changed  electrical  reactions  which  we  have 
previously  described.  The  extent  of  the  deviation  of  these  reactions 
from  the  normal  is  usually  a  good  indication  of  the  probable  duration  of 
the  disease.  Those  in  which  the  reactions  are  normal  or  are  only  some- 
what diminished  in  quantity,  not  in  quality,  will  probably  recover  within 
a  couple  of  weeks.  In  exceptional  cases,  however,  these  reactions  per- 
sist for  several  months,  and  the  disease  may  run  a  tedious  course.  Fi- 
nally, Brenner  has  reported  cases  in  which  the  irritability  of  the  nerves 
to  both  currents  is  heightened  for  several  weeks.  It  is  also  stated  that 
electrization  of  the  healthy  muscles  will  sometimes  give  rise  to  contraction 
of  the  paralyzed  ones;  this  may,  however,  be  due  to  diffusion  of  the  cur- 
rent. In  cases  of  long  standing,  and  in  all  incurable  cases,  the  muscles, 
and  apparently  also  the  skin,  undergo  a  certain  amount  of  atrophy. 
This  is  frequently  so  slight  that  careful  scrutiny  is  necessary  to  detect  it. 
The  entire  paralyzed  side  of  the  face  appears  to  be  smaller  than  the  un- 
affected, the  bones  are  more  prominent,  and  the  integument  appears  to  be 
thinner.  This  is  not  pathognomonic  of  a  peripheral  affection,  as  I  have 
sometimes  observed  the  same  condition  in  facial  hemiplegia,  which  was 
undoubtedly  due  to  a  cerebral  lesion  acquired  in  early  life.  In  cerebral 
facial  paralysis  of  adults  these  changes  are  never  observed. 
14 


210  FUNCTIONAL    NERVOUS    DISEASES. 

Sensory  disturbances  are  extremely  rare  in  the  disease  under  considera- 
tion, and  their  occurrence  has  been  disputed.  I  have  noticed,  however,  in 
a  few  severe  cases  of  rlieuinatic  facial  paralysis  that  the  patients  complain- 
ed of  numbness  of  the  cheek,  and  have  found  that  tactile  sensation  was 
not  as  distinct  as  on  the  opposite  side,  though  no  change  could  be  detect- 
ed with  the  aesthesiometer.  These  symptoms  are  undoubtedly  due  to 
implication  of  some  of  the  recurrent  fibres  of  the  trigeminus  by  the  pri- 
mary lesion. 

An  interesting,  though  infrequent,  feature  of  facial  paralysis  is  the 
occurrence  of  spasms  and  contractures  in  the  affected  muscles.  The 
spasms  may  be  either  of  a  tonic  or  clonic  character,  and  are  usually  the 
precursors  of  contracture. 

The  muscular  spasms  generally  affect  only  a  few  muscles  at  a  time, 
and  may  occur  spontaneously  or  during  mental  emotion,  attempted  volun- 
tary action,  etc.  They  are  not  infrequently  accompanied  by  increased 
mechanical  irritability  of  the  parts.  When  the  spasmodic  movements 
are  well  marked  and  general,  they  simulate  facial  tic. 

Contracture  of  the  paralyzed  muscles  is  generally  preceded,  as  we  have 
stated  above,  by  tonic  or  clonic  spasms.  Duchenne  *  states  that  the 
rapid  development  of  tonicity  in  a  completely  paralyzed  muscle  which  has 
lost  its  faradic  excitability,  is  an  indication  that  it  will  become  contrac- 
tured  at  a  later  period.  Either  a  single  muscle  or  the  entire  group  of  facial 
muscles  may  be  affected.  When  all  are  involved,  the  eye  appears  slightly 
smaller  than  its  fellow,  the  ala  nasi  is  drawn  upward,  the  naso-labial  fold  is 
deeper  and  higher  than  the  one  on  the  normal  side,  the  upper  lip  is  drawn 
upward  and  a  little  outward,  so  that  a  portion  of  the  teeth  is  continually 
exposed,  and  the  lower  lip  is  everted.  These  changes  are  not  so  general,  of 
course,  when  only  a  few  muscles  are  contractured.  In  the  larger  number 
of  cases  the  affected  muscles  are  also  subject  to  tonic  or  clonic  spasms. 
This  condition  not  infrequently  leads  to  mistakes  in  diagnosis,  since,  at  first 
sight,  the  deepening  of  the  naso-labial  fold  on  the  affected  side  may  lead 
to  the  suspicion  that  the  opposite  side  is  paralyzed.  I  remember  a  case 
in  which  a  well-known  neurologist  of  this  city  fell  into  this  error  and  mis- 
took a  paralysis  of  the  left  lower  facial  muscles  for  an  affection  of  the 
right  side.  At  first  sight  I  was  also  of  the  opinion  that  the  affection  was 
on  the  right  half  of  the  face,  but  upon  asking  the  patient  to  move  the 
muscles,  I  found  that  those  on  the  right  side  could  be  contracted  with 
perfect  facility,  while  those  on  the  left,  and  apparently  healthy  side,  were 
immovable.  Upon  questioning  the  patient  as  to  the  history  of  the  dis- 
ease, it  became  evident  that  the  left  half  of  the  face  had  been  at  first  com- 
pletely paralyzed,  and  that  contracture  developed  at  a  later  period. 
Trousseau  also  mentions  a  case  of  this  kind,  in  which  the  paralysis  was 
supposed  to  be  on  the  healthy  side  of  the  face  by  several  medical  men 
who  had  seen  the  patient.  Careful  examination  of  the  motility  of 
both  halves  of  the  face  will,  however,  always  enable  us  to  make  a  cor- 
rect diagnosis  with  regard  to  the  seat  of  the  disease.  The  contracture 
of  the  muscles  is  probably  due  to  atrophy  of  the  muscular  fibres  and  to 
retraction  of  the  newly  formed  interstitial  connective  tissue,  which  thus 
causes  shortening.  If  this  process  ceases  before  it  becomes  excessive,  it 
may  entirely  overcome  the  deformity  caused  by  the  paralysis,  so  that  no 
difference  is  observed  in  the  two  halves  of  the  face  unless  the  movements 
of  the  healthy  side  are  very  marked. 

'  Electrisation  localisee. 


PERIPHERAL    PARALYSIS.  211 

Double  facial  paralysis  (diplegia  facialis)  is  extremely  rare  as  a  peri- 
pheral affection,  though  it  is  not  very  uncommon  as  the  result  of  central 
diseases.  But,  as  we  shall  see  in  the  chapter  on  diagnosis,  the  latter 
usually  affect  only  the  lower  facial  muscles.  The  appearances  presented 
in  diplegia  facialis  are  very  striking.  All  expression,  except  that  of  the 
eyes,  is  lost;  the  natural  folds  and  wrinkles  of  the  face  are  entirely 
effaced.  The  lower  lip  droops  and  the  saliva  dribbles  down  the  chin. 
The  eyes' are  widely  open  and  staring,  and  remain  so  even  during  sleep. 
Though  the  patient  laugh  ever  so  heartily,  the  features  remain  perfectly 
immovable.  The  disturbances  of  speech  are  much  more  marked  than  in 
unilateral  paralysis,  and  the  interference  with  deglutition  is  also  very 
annoying  on  account  of  the  passage  of  food  between  the  cheeks  and 
teeth.  The  electrical  reactions  vary  in  no  respect  from  those  observed 
in  like  cases  of  unilateral  paralysis.  The  duration  and  course  of  the 
disease  is  also  entirely  similar  to  those  already  described  in  the  unilateral 
variety. 

Etiology. 

The  majority  of  cases  of  this  disease  are  due  to  so-called  rheumatic 
causes.  They  occur  from  exposure  to  a  draught  and  sometimes  while 
merely  working  or  playing  in  the  open  air.  The  paralysis  develops  imme- 
diately after  the  exposure,  or  a  period  of  one  or  two  days  may  elapse;  in 
all  cases,  it  attains  its  greatest  severity  within  a  short  period  after  its  in- 
ception. A  considerable  proportion  of  these  cases  are  attended  with  loss 
of  taste  in  the  anterior  third  of  the  tongue  on  the  affected  side;  the  velum 
palati  and  uvula  are,  however,  rarely  implicated.  It  is  presumed  that  in 
this  form  a  certain  degree  of  neuritis  develops  in  that  portion  of  the  facial 
nerve  which  passes  through  the  Fallopian  canal,  and  that  the  severity  of 
the  paralysis  varies  with  the  amount  of  plastic  exudation  into  the  tissue 
of  the  nerve. 

Light  forms  of  facial  paralysis  may  disappear  in  from  twelve  to 
twenty-four  hours,  and  it  is  extremely  improbable  that  any  inflammatory 
exudation  could  be  absorbed  in  this  short  space  of  time.  We  are  there- 
fore led  to  suppose  that  a  simple  congestion  of  the  nerve  may  give  rise 
to  temporary  loss  of  power. 

Inflammatory  diseases  of  the  middle  ear  or  carious  or  necrotic  proces- 
ses of  the  petrous  portion  of  the  temporal  bone  in  the  neighborhood  of 
the  Fallopian  canal  also  act  as  frequent  causes  of  the  disease.  In  such 
cases  the  paralysis  usually  develops  slowly,  one  twig  of  the  nerve  being 
affected  after  the  other.  In  some  of  these  cases  it  is  probable  that  the 
paralysis  is  due  to  a  direct  spread  of  the  inflammation  from  the  middle  ear 
to  the  adjacent  nerve,  giving  rise  to  various  grades  of  neuritis  or  perineu- 
ritis. In  the  milder  forms,  it  is  probable,  as  in  mild  rheumatic  paralysis, 
that  there  is  simple  congestion  of  the  nerve.  The  sense  of  taste  is  fre- 
quently implicated  in  facial  paralysis  from  ear  disease,  but  the  velum 
palati  and  uvula  are  rarely,  if  ever  involved.  Disturbances  of  hearing  due 
to  the  primary  aural  disease  are,  of  course,  always  present;  but,  in  addi- 
tion, the  hyperakusis  which  was  described  on  page  208,  is  often  noticeable. 

Quite  a  number  of  cases  are  due  to  a  lesion  of  the  nerve  after  its  exit 
from  the  stylo-mastoid  foramen.  This  category  includes  direct  injury  to 
the  nerve  by  a  knife  or  bullet  wound,  blow  upon  the  face  with  the  fist,  a 
stone,  etc.,  compression  of  the  nerve  by  the  forceps  during  delivery,  the 
spread  of  inflammation  from  abscesses  of  the  parotid  gland,  implication 


212  l^UNCTIOFAL    NERVOUS   DISEASES. 

of  the  nerve  in  new-growths  developing  in  the  gland  or  in  the  adjacent 
tissues,  division  of  the  nerve  by  the  knife  of  the  surgeon  in  opening  ab- 
scesses, extirpating  tumors,  etc.  A  characteristic  phenomenon  in  this 
variety  of  the  disease  is  the  fact  that  only  a  few  of  the  muscles  are  usually 
involved,  and  even  when  all  are  affected,  the  paralysis  travels  gradually 
from  one  muscle  to  the  other.  This  is  due  to  the  anatomical  arrangement 
of  the  nerve-fibres  after  their  exit  from  the  stylo-mastoid  foramen,  the 
nerves  spreading  out  and  becoming  separated  from  one  another.  The 
paralysis  is  usually  severe,  the  muscles  undergo  atrophy,  present  the  degen- 
eration-reaction, and  often  remain  paralyzed  irremediably;  contracture  of 
the  affected  muscles  is  not  an  infrequent  result.  The  chorda  tympani  is 
not  involved  in  this  variety,  and  implication  of  the  velum  palati  and  uvula 
is  also  absent.  Paralysis  from  pressure  of  the  forceps  during  delivery  was 
first  described  by  Osiander  and  Landouzy.  When  the  infant  is  quiet,  it  is 
very  difficult  and  often  impossible  to  detect  any  paralysis,  as  the  natural 
folds  of  the  face  are  very  poorly  marked  in  the  young.  As  soon  as  the 
child  begins  to  cry,  however,  the  immobility  of  the  paralyzed  side  and  the 
consequent  deformity  become  very  distinct.  The  affection  is  usually  mild 
and  recovers  spontaneously  within  a  few  weeks. 

Intracranial  diseases  may  also  produce  peripheral  paralysis  of  the  sev- 
enth nerve;  we  exclude  from  this  variety  all  those  cases  which  are  due 
to  an  affection  of  the  central  nervous  system.  This  category  includes 
basilar  meningitis,  the  exudation  in  which  produces  pressure  and  atrophy 
of  the  nerve,  periostitis  of  the  petrous  portion  of  the  temporal  bone,  ex- 
ostoses and  tumors  growing  from  the  base  of  the  skull,  aneurisms  of  the 
vessels  at  the  base  of  the  brain.  The  nerve  is  paralyzed,  in  these  cases, 
in  its  entire  distribution.  It  appears,  however,  from  the  history  of  re- 
ported cases  (and  I  can  substantiate  this  by  my  own  experience  in  several 
cases)  that  the  sense  of  taste  is  not  impaired.  This  fact  seems  to  in- 
dicate that  the  chorda  tympani  does  not  leave  the  brain  with  the  seventh 
nerve,  but  enters  the  latter  in  some  of  the  numerous  anastomoses  which 
it  forms  with  the  trigeminus,  giosso-pharyngeal  and  vagus.  It  is  charac- 
teristic of  this  variety  of  facial  paralysis  that  it  is  always  attended  with 
paralysis  of  some  of  the  other  cranial  nerves,  or  perhaps  with  irregularity 
of  the  pupils,  double  vision,  amaurosis,  headache,  and  later  with  paralysis 
of  the  limbs.  The  electrical  reactions  of  the  muscles  vary  with  the  se- 
verity of  the  disease,  and  present  as  many  variations  as  are  produced  in 
the  rheumatic  form.  Like  the  paralysis  produced  by  middle-ear  trouble, 
this  variety  is  also  produced  slowly,  as  a  rule,  the  loss  of  power  gradually 
deepening,  and  one  mmscle  sometimes  becoming  affected  after  the  other. 
The  disease  is  naturally  very  chronic,  its  recovery  depending  upon  the 
curability  of  the  primary  disease. 

Syphilis  generally  gives  rise  to  peripheral  facial  paralysis  by  producing 
lesions  similar  to  those  of  the  intracranial  diseases  mentioned  above. 
Thus,  it  may  produce  periostitis,  exostoses,  gummata,  or  chronic  basilar 
meningitis.  In  rare  instances  the  syphilitic  lesions  are  situated  along 
the  course  of  the  nerve  through  the  Fallopian  canal,  or  even  after  its  exit 
from  the  stylo-mastoid  foramen.  The  paralysis  is  general  (affecting  all 
branches  of  the  nerve)  and  usually  develops  slowly.  The  disease  gener- 
ally disappears  promptly  under  appropriate  treatment. 

Finally,  we  must  refer  to  the  development  of  peripheral  facial  paraly- 
sis as  a  sequela  of  certain  of  the  infectious  diseases  (diphtheria,  variola, 
scarlatina).  These  cases  are  very  rare,  and  their  clinical  history  differs  in 
no  respect  from  that  described  on  page  178. 


PERIPHERAL    PARALYSIS.  213 

Diplegia  facialis  results  most  frequently  from  some  affection  at  the 
base  of  the  brain  which  gives  rise  to  pressure  on  both  seventh  nerves  at 
their  exit  from  the  lower  border  of  the  pons  (basilar  meningitis,  tumor). 
It  may  also  be  produced  by  an  injury  which  has  given  rise  to  an  extrava- 
sation of  blood  into  each  middle  ear,  or  by  the  presence  of  double  otitis 
media.  A  few  cases  have  also  been  reported  in  which  it  was  of  a  purely 
rheumatic  origin,  the  paralyses  usually  developing  at  an  interval  of  a 
couple  of  days.  In  still  another  series  of  cases  the  affection  may  have  a 
different  origin  on  the  two  sides.  Thus,  it  may  be  due  to  middle-ear  dis- 
ease on  one  side,  and  be  of  a  rheumatic  character  on  the  other,  etc. 


Diagnosis  and  Prognosis. 

The  diagnosis  of  facial  paralysis  is  extremely  simple;  in  addition  to 
noting  the  absence  of  the  naso-labial  fold  and  the  wrinkles  on  the  fore- 
head, the  drooping  of  the  angle  of  the  mouth,  it  is  merely  necessary  to 
direct  the  patient  to  laugh,  when  the  characteristic  deformity  will  imme- 
diately appear.  In  those  cases  in  which  contracture  of  the  muscles  has 
occurred,  and  the  folds  of  the  face  have  therefore  been  restored,  we  must, 
in  addition  to  making  a  careful  inspection  of  the  parts,  obtain  a  history 
of  the  beginning  of  the  affection  and  of  the  appearances  then  presented. 
The  exercise  of  a  moderate  amount  of  care  in  the  examination  will  always 
enable  us  to  avoid  making  a  mistake  in  these  cases  (vide  page  210.) 

After  having  made  a  diagnosis  of  paralysis,  we  must  determine  whether 
it  is  of  peripheral  or  central  origin.  The  history  of  the  case  is  of  great 
importance  in  this  respect.  The  fact  that  the  affection  developed  after 
exposure  to  a  well-defined  peripheral  cause  (exposure,  blow,  etc.),  its 
occurrence  without  any  cerebral  symptoms  or  without  the  presence  of 
paralysis  in  any  other  portion  of  the  body,  the  implication  of  the  orbicularis 
palpebrierum,  occipito-frontalis  and  corrugator  supercilii,  diminution  in 
the  electrical  reactions  of  the  nerves  and  muscles,  and,  not  infrequently, 
the  presence  of  the  degeneration-reaction,  the  disturbance  of  taste  in  the 
distribution  of  the  chorda  tympani  (anterior  third  of  tongue),  the  paraly- 
sis of  the  velum  palati  and  uvula — all  these  symptoms  are  valuable  indica- 
tions of  the  peripheral  nature  of  the  affection.  But  certain  central 
paralyses  of  the  seventh  nerve,  due  to  affections  of  the  pons  varolii,  are 
differentiated  with  great  difficulty  from  the  peripheral  forms.  Tumors, 
hemorrhages,  abscesses,  etc.,  of  the  pons  varolii  may  be  symptomatized 
by  facial  paralysis,  in  which  all  the  facial  muscles  are  affected,  as  in  the  or- 
dinary peripheral  variety,  and  in  which  the  electrical  reactions  correspond 
to  those  observed  in  the  latter.  Two  cases  of  this  kind  are  reported  by 
Rosenthal.'  As  a  rule,  however,  some  of  the  other  cranial  nerves  are 
implicated  either  simultaneously  with  the  facial  or  after  a  variable  period, 
and,  in  addition,  the  limbs  become  paralyzed  on  the  side  of  the  body  op- 
posite to  the  paralysis  (crossed  paralysis). 

The  peculiar  anatomical  arrangement  of  the  seventh  nerve  and  its 
branches  enables  us,  in  very  many  instances,  to  determine  the  exact  site 
of  the  lesion  which  has  given  rise  to  the  affection. 

When  the  lesion  is  situated  between  the  exit  of  the  seventh  nerve 
from  the  brain  and  the  ganglion  geniculatum,  the  paralysis  involves  all 
the  facial  muscles,  the  velum  palati  and  uvula  are  implicated,  but  the 

>  Clinical  Treatise  on  Diseases  of  the  Nervous  System,  pp.  126  and  127. 


214  FUNCTIONAL    NERVOUS    DISEASES. 

sense  of  taste  is  not  affected;  the  disturbances  of  audition  (oxyokoioa)  to 
■which  we  have  previously  referred  are  also  present.  The  absence  of  any 
disturbance  of  taste  appears  to  corroborate  the  theory  of  Schiff,  v\^ho 
states  that  the  chorda  tympani  enters  the  seventh  nerve  in  the  petrosus 
snperficialis  major,  and  any  lesion  situated  above  the  genu  would  there- 
fore not  interfere  with  gustation.  If  the  lesion  is  situated  between  the 
ganglion  geniculatum  and  the  point  at  which  the  chorda  tympani  leaves 
the  Fallopian  canal,  the  symptoms  will  vary  slightly  from  those  described 
above.  The  velum  palati  and  uvula  will  be  unaffected;  there  will  be  an 
interference  with  gustation,  however,  in  the  anterior  third  or  half  of  the 
tongue  on  the  paralyzed  side.  When  the  lesion  is  outside  of  the  Fallo- 
pian canal,  the  only  symptoms  present  are  those  dependent  on  paralysis 
of  all  the  facial  muscles;  in  such  cases  there  is  no  interference  with  any 
of  the  special  senses. 

In  addition  to  determining  the  seat  of  the  lesion,  we  should  also  en- 
deavor to  ascertain  its  nature.  This  is  usually  done  with  readiness,  and 
is  determined  by  a  knowledge  of  the  history  of  the  case  and  of  the  pre- 
existing diseases  from  which  the  patient  has  suffered.  Caution  must  be 
exercised,  however,  in  pronouncing  the  affection  of  a  syphilitic  nature,  as 
there  is  a  tendency  to  consider  all  nervous  diseases  as  syphilitic  which 
occur  in  a  patient  who  suffers  from  this  affection.  It  is  therefore  well  to 
exclude  all  other  causes  before  attributing  the  paralysis  to  syphilis. 

The  prognosis  depends,  of  course,  upon  the  nature  of  the  cause. 
When  it  is  due  to  some  irremediable  organic  lesion,  the  paralysis  will  not 
disappear,  and  will  usually  be  followed  by  atrophy  and  contracture  of  the 
muscles.  The  electrical  reactions  of  the  nerves  and  muscles  are  a  valua- 
ble indication  of  the  probable  duration  of  the  disease,  as  we  have  shown  at 
length  in  our  general  remarks  on  peripheral  paralysis.  But  even  in  those 
cases  in  which  the  electro-muscular  contractility  to  both  currents  has  en- 
tirely disappeared,  we  should  not  abandon  all  hope  of  final  recovery,  as  a 
case  of  this  kind  has  come  under  my  notice  in  which  persevering  treat- 
ment led  to  a  favorable  termination. 


Teeatment. 

In  syphilitic  facial  paralysis,  the  use  of  anti-syphilitic  remedies  alone 
is  sufficient,  in  the  majority  of  cases,  to  cure  the  disease.  In  those  rare 
forms  which  occur  in  the  early  secondary  stage,  mercurials  are  indi- 
cated ;  in  the  commdner  varieties,  due  to  tertiary  lesions,  the  mixed 
treatment  should  be  employed.  The  iodide  of  potassium,  as  we  have  so 
frequently  insisted,  should  be  administered  in  continually  increasing 
doses  until  the  desired  effect  is  produced. 

When  the  disease  is  due  to  otitis  media  or  some  other  affection  of  the 
middle  ear,  the  chief  attention  should  be  devoted  to  the  treatment  of  the 
latter.  Great  importance  must  be  attached  to  the  frequent  use  of  mild 
injections  into  the  ear,  the  treatment  of  any  pharyngeal  catarrh  which 
may  be  present,  etc.,  etc.  For  further  details  on  this  subject  we  must 
refer  to  the  text-books  on  otology.  This  variety  of  paralysis  is  usually 
very  chronic,  and  electrical  treatment,  employed  in  the  manner  which  we 
shall  describe  later  on,  becomes  very  important. 

Surgical  measures  become  necessary  where  the  affection  is  due  to  the 
presence  of  abscesses,  tumors,  etc.,  in  the  vicinity  of  the  nerve  after  its 
exit  from  the  stylo-mastoid  foramen.     No  general  advice  can  be  given  with 


PERIPHERAL    PARALYSIS.  215 

regard  to  the  treatment  of  this  form,  as  everything  depends  upon  tlie  pecu- 
liarities of  the  individual  case.  When  resort  is  had  to  the  knife,  however, 
the  incisions  should  be  as  small  and  superficial  as  possible,  in  order  to  ob- 
viate division  of  the  nerve,  regeneration  of  which  does  not  readily  occur 
in  this  situation. 

In  some  forms  of  rheumatic  paralysis  no  treatment  is  required,  as  the 
affection  disappears  spontaneously  within  a  period  of  one  or  two  weeks  ; 
tlie  majority  of  cases,  however,  demand  careful  attention.  Within  the 
first  few  days  it  is  advisable  to  place  two  or  three  leeches  behind  the  ear 
and  then  apply  a  blister  over  the  mastoid  process.  It  is  doubtful,  how- 
ever, whether  any  decided  benefit  is  obtained  from  these  measures.  The 
use  of  strychnia  is  also  recommended,  but  I  have  never  seen  the  slightest 
advantage  from  its  administration,  and  have  long  since  discontinued  this 
remedy.  It  is  advisable  to  keep  the  eye  covered  with  a  shade  in  order 
to  prevent  irritation  from  foreign  particles.  This  simple  measure  often 
prevents  serious  annoyance  from  this  cause. 

Practically,  our  only  resource  consists  in  the  application  of  elec- 
tricity. When  the  muscles  react  to  faradism,  this  current  should  be 
used  in  preference,  an  ordinary  electrode  being  placed  over  the  mastoid 
process,  and  the  other  smaller  one  (about  the  size  of  a  five-cent  piece), 
being  placed  over  the  various  paralyzed  muscles.  The  current  should 
merely  be  strong  enough  to  produce  visible  muscular  contractions,  and 
three  sittings  weekly,  of  four  to  five  minutes'  duration,  are  amply  suffi- 
cient. In  milder  cases,  or  when  recovery  is  almost  complete,  the  nerves 
also  react  to  faradism  ;  in  this  event,  one  electrode  is  placed  in  the  mas- 
toid fossa,  and  the  other  is  slowly  passed  up  and  down  the  face  in  a  line 
passing  from  a  point  a  little  behind  the  outer  angle  of  the  eye  to  the 
angle  of  the  jaw.  In  this  manner  all  the  branches  of  the  nerve  are  sub- 
jected to  the  action  of  the  current.  When  the  nerves  are  insensible  to 
faradism  but  react  to  galvanism,  the  latter  current  should  be  employed 
in  the  same  manner,  the  positive  electrode  being  placed  in  the  mastoid 
fossa  and  the  negative  passed  over  the  trunks  of  the  nerves.  When  the 
electrode  is  moved  to  and  fro  in  this  way,  it  is  unnecessary  to  inter- 
rupt the  current,  as  the  mere  passage  of  the  electrode  over  the  muscles 
suffices  for  this  purpose.  When  the  muscles  alone  react  to  galvanism, 
the  positive  pole  is  retained  in  the  mastoid  fossa,  the  negative  being 
placed  over  the  individual  muscles  (vide  Fig.  1).  In  this  case  it  is  neces- 
sary to  interrupt  the  current,  and  this  is  readily  effected  by  pressing  upon 
an  interrupter  placed  in  the  handle  of  one  of  the  electrodes.  Here,  again, 
it  is  merely  requisite  to  obtain  a  visible  muscular  contraction.  Even  when 
the  electrical  irritability  of  the  nerves  and  muscles  is  entirely  abolished, 
treatment  should  be  steadily  continued  unless  the  nature  of  the  cause  of 
the  paralysis  precludes  the  possibility  of  recovery.  It  is  preferable,  in 
these  cases,  to  employ  the  uninterrupted  constant  current  through  the 
nerves,  and  the  sittings  may  be  held  daily. 

Dr.  Seguin'  has  described  an  intra-buccal  method  of  applying  elec- 
4;ricity  to  the  lower  facial  muscles.  The  electrode  "  consists  of  an  ordi- 
nary interrupting  handle,  armed  with  a  rod-like  electrode  of  moderate 
length,  bent  at  a  right  angle  near  its  extremity,  and  terminating  in  a  ball 
five  millimetres  in  diameter.  The  whole  of  the  rod  or  stem,  except  the 
ball,  should  be  completely  insulated."  This  may  be  used  upon  all  the 
lovver  facial   muscles,  the  ball   being  placed  on  the  buccal  mucous  mem- 

'  Archives  of  Medicine,  Feb.,  1880. 


216  FUJJ^CTIONAL   NERVOUS    DISEASES. 

brane  at  parts  corresponding  to  the  motor  points  externally.  Dr.  Seguin 
claims  to  be  thus  able  "in  the  stage  of  recovery  of  rheumatic  facial 
paralysis,  to  obtain  distinct  contractions  with  faradism  when  the  strong- 
est currents  which  could  be  tolerated  on  the  skin  of  the  face  did  not 
produce  them." 

It  is  held  that  the  slow  progress  of  recovery  in  many  cases  of  facial 
paralysis,  as  in  various  other  peripheral  paralyses,  is  very  materially , 
retarded  and  often  entirely  stopped  on  account  of  the  elongation  of  the 
muscles,  which  is  caused  by  the  unopposed  contraction  of  the  antago- 
nists. Various  devices  have  been  suggested  in  order  to  overcome  this 
feature.  The  most  effective  is  one  recommended  by  Dr.  Van  Bibber  of 
Baltimore,  who  advises  the  following  plan  :  a  metallic  hook  is  introduced 
into  the  angle  of  the  mouth,  and  ia  connected  with  a  piece  of  india  rub- 
ber which  is  fastened  around  the  ear.  By  means  of  this  the  desirable 
amount  of  traction  can  be  exercised  upon  the  angle  of  the  mouth  and 
the  elongation  of  the  muscles  thus  obviated. 

The  treatment  of  facial  paralysis  following  acute  infectious  diseases 
is  identical  with  that  of  the  rheumatic  forms.  Various  measures  have 
been  recommended  in  the  treatment  of  contracture  of  the  affected 
muscles,  none  of  which,  however,  offer  much  chance  of  success  ;  these 
include  galvanization  of  the  contractured  muscles,  the  application  of 
faradism  to  the  antagonistic  healthy  ones,  mechanical  elongation  of  the 
affected  parts  by  stretching  them  with  the  fingers,  or  keeping  a  rubber 
ball  in  the  cheek,  and  even  incision  of  the  muscles.  The  latter  plan 
should  not  be  adopted  under  any  circumstances,  as  it  will  only  serve  to 
increase  the  deformity  after  reunion  of  the  divided  parts  has  occurred. 


PERIPHERAL    PARALYSIS. 


217 


CoTTugator  snpercilii- 

Compressor  nasi 
Orbicularis  palpebrsemm 
Levator  labii  sup.  alseque. 

nasi. 
Levator  labii  sup.  proprius- 
Zygomatic.  minor 

Dilator  narium  , „ 

I  post. 

Zygomatic,  major 

Orbicularis  oris 


Frontal  muscle. 

Attrahens  &  attolens  aurem. 

Retrahens  aurem. 

Occipital  mu'scle. 
Facial  nerve. 
Posterior  auricular  nerve.    , 


branches  of  the  faciaL 


N.  to  Irianga^larifi  &  lev.  menti 
Levator  menti 
Qnadratus 
Triangulari: 

Cervical  branches  of  facial- 
nerve. 


utan.  branch  of  inf.  maxillary. 
Spinal  accessory  nerve. 
Branch  to  stemo- mastoid. 
Branch  to  trapezius. 

Stemo-mastoid. 
Levator  anguli  scapulae. 


•Phrenic  nerve. 


Posterior  thoracic  nerve 
(serratus  magnus). 


Axillary  nerve. 


PlO.  1. — Motor  points  of  the  face,  showing  the  position  of  the  electrodes  in  electrization  of  the  facial 
nerve  and  muBcles.  The  anode  is  placed  in  the  mastoid  fossa,  and  the  cathode  upon  the  part  indicated  ia 
the  figure. 


CHAPTEE  YII. 

PAEALYSIS  OF  TKE  SPINAL  ACCESSORY.' 
Clinical  Histoet. 

This  form  of  paralysis  is  extremely  rare,  but  the  symptoms  produced 
are  very  characteristic,  and  agree  in  all  respects  with  those  observed  after 
extirpation  of  the  nerve  in  physiological  experiments.  The  external  or 
muscular  branch  is  much  more  frequently  affected  than  the  internal. 
Paralysis  of  the  former  nerve  gives  rise  to  partial  loss  of  power  in  the 
sterno-cleido-mastoid  and  trapezius. 

When  the  former  muscle  is  paralyzed,  the  head  is  drawn  by  the  unop- 
posed action  of  the  corresponding  healthy  one  in  such  a  manner  that 
the  mastoid  process  on  the  unaffected  side  is  brought  closer  to  the  sternum 
and  the  chin  is  carried  horizontally  toward  the  paralyzed  side.  If  con- 
tracture of  the  healthy  sterno-mastoid  develops  (and  this  may  occur  after 
the  paralysis  has  lasted  for  a  long  time),  the  head  is  permanently  fixed  in 
this  abnormal  position.  When  atrophj*  of  the  muscle  occurs,  the  normal 
protrusion  of  its  belly  is  lost,  and  the  diminution  in  size  can  also  be  ap- 
preciated by  rolling  it  between  the  fingers  and  comparing  it  with  the 
healthy  one.  The  power  of  flexing  the  head  and  at  the  same  time  ap- 
proximating the  chin  to  the  opposite  shoulder  is  lost.  Paralysis  of  the 
trapezius,  when  accompanied  by  atrophy,  may  also  be  visible  to  the  naked 
eye  upon  comparing  the  muscle  with  its  fellow,  especially  when  the  pa- 
tient is  directed  to  elevate  both  shoulders.  The  scapula  is  lower  upon 
the  paralyzed  than  upon  the  healthy  side,  and  its  posterior  border  is 
drawn  farther  away  from  the  spine  on  account  of  the  unopposed  action  of 
the  serratus  magnus.  The  elevation  of  the  shoulder  is  diminished  though 
not  entirely  prevented,  as  the  levator  anguli  scapulse  and  rhomboidei  are 
brought  more  vigorously  into  play,  and  thus  partially  supply  the  deficiency 
of  the  trapezius.  In  addition,  the  power  of  raising  the  arm  above  the  hor- 
izontal is  somewhat  impaired,  as  the  trapezius  aids  the  serratus  magnus 
in  this  action  by  the  contraction  of  its  anterior  fibres  which  elevate  the 
acromial  end  of  the  scapula.  As  in  paralysis  of  the  sterno-cleido-mas- 
toid, the  antagonist  muscle  (in  this  case  the  serratus  magnus)  may  be- 
come contractured,  and  this  will  result  in  drawing  the  scapula  perma- 
nently downward  and  away  from  the  spinal  column. 

More  commonly  the  external  branch  of  the  spinal  accessory  is  alone 
affected;   at  times,  however,  the  internal  anastomotic  branch  is  also  in- 

'  The  spinal  accessory  nerve  divides  into  two  branches,  the  internal  or  anastomotic, 
and  the  external  or  muscular.  The  I'ormer  passes  to  the  pneumojjastric.  and  supp'.ies 
some  of  the  muscles  of  the  velum  palati,  the  coastrictors  of  the  pharynx,  and  all  the 
muscles  of  the  Inryux  which  are  concerned  in  phonation  ;  this  branch  also  possesses 
an  inhibitory  influence  upon  the  heart.  The  external  branch  is  distributed  to  the 
Bterno-cleido-mastoid  and  trapezius,  but  these  muscles  also  receive  a  portion  of  their 
nerve-supply  from  the  two  up2>er  cervical  nerves. 


PEEIPHEKAL   PAEALTSIS.  219 

volved.  On  account  of  the  fact  that  the  innervation  of  these  muscles  is 
derived  from  various  sources,  it  is  sometimes  found  that  the  muscles  are 
not  paralyzed  in  their  entirety,  but  that  only  a  few  bundles  are  affected. 

The  electrical  reactions  have  not  been  inquired  into  very  thoroughly, 
but  in  most  of  the  cases  in  which  attention  has  been  paid  to  this  point, 
thev  were  simply  diminished,  Erb  reports  a  case,  however,  in  which  the 
degeneration-reaction  was  present.  Lesion  of  the  internal  branch  of  the 
spinal  accessory  gives  rise  to  paralysis  of  the  velum  palati,  the  muscles 
of  the  pharynx,  and  those  muscles  of  the  larynx  which  are  engaged  in 
phonation.  In  paralysis  of  both  nerves,  the  velum  palati  has  been  found 
completely  motionless;  the  voice  in  consequence  has  a  nasal  twang,  and 
fluids  are  apt  to  regurgitate  through  the  nose.  The  loss  of  power  in  the 
constrictors  of  the  pharynx  causes  difficulty  in  swallowing,  the  food  "  sticks 
in  the  throat,"  and  the  patient  exerts  unusual  effort  in  forcing  it  down- 
ward. Unilateral  paralysis  of  the  muscles  of  the  larynx  causes  hoarse- 
ness and  huskiness  of  the  voice,  which  is  not  as  loud  as  usual;  upon  ex- 
amination with  the  laryngoscope,  the  vocal  cord  on  the  affected  side  is 
found  to  be  motionless  during  an  attempt  at  articulation,  while  that  of 
the  opposite  side  often  passes  beyond  the  median  line.  When  both  vocal 
cords  are  paralyzed,  complete  aphonia  is  produced.  The  incomplete 
closure  of  the  glottis  often  allows  particles  of  food  to  enter  the  larynx, 
and  thus  gives  rise  to  paroxysms  of  cough. 

The  spinal  accessory  nerve  also  possesses  an  inhibitory  influence  upon 
the  action  of  the  heart,  but  no  effect  is  produced  upon  the  character  of 
the  pulse  when  only  one  nerve  is  affected;  when  both  are  involved,  the 
pulse  may  be  increased  in  frequency.  The  following  case,  which  was  re- 
ported in  detail  by  Seeligmueller,  '  illustrates  most  of  the  symptoms  to 
which  we  have  referred. 

Case  VL — Amelia  F.,  jet.  24  years;  the  patient  was  healthy  until  nine 
years  ago,  at  which  time  she  was  compelled  to  carry  very  hea'^^y  vessels  of 
water  upon  the  back.  These  often  spilled,  the  water  running  down  the 
neck  and  back.  Shortly  afterward,  cough  and  pain  developed  on  the  right 
side.  At  the  same  time  the  neck  became  very  much  swollen  on  both  sides, 
and  the  patient  experienced  considerable  difficulty  in  swallowing;  the  lat- 
ter symptom  did  not  disappear  after  the  swelling  had  subsided,  and  was 
therefore  unconnected  with  it.  The  solid  food  frequently  "  stuck  in  the 
throat,"  and  fluids  were  regurgitated  through  the  nose.  The  patient  ex- 
perienced a  certain  amount  of  difficulty  in  speaking,  and  the  respiration 
was  stertorous.  Four  years  ago  the  preceding  symptoms  became  compli- 
cated with  gradually  increasing  weakness  of  the  left  arm.  About  the 
same  time  the  patient  noticed  bilateral  atrophy  in  the  region  of  the  neck. 

Present  condition. — Upon  inspection,  the  facial  muscles  appear  nor- 
mal and  can  be  well  contracted.  The  uvula  is  not  in  the  median  line, 
but  is  deflected  considerably  toward  the  right  side,  so  that  the  right  arch 
of  the  palate  is  much  narrower  and  hig'her  than  that  on  the  left  side;  the 
velum  palati  and  uvula  remain  motionless  when  irritated  or  when  an  at- 
tempt is  made  at  phonation.  Upon  laryngoscopic  examination,  the  rima 
glottidis  is  found  to  be  widely  opened,  and  the  vocal  cords  do  not  change 
their  position  during  respiration  or  when  the  patient  is  directed  to  artic- 
ulate. 

The  sterno-cleido-mastoids  are  markedly  atrophied,  but  unequally  in 

1  Arch,  t  Psych.  Bd.  ni.,  p.  433. 


220  FUNCTIONAL    NERVOUS    DISEASES. 

different  portions  of  the  muscles;  the  bundles  which  are  inserted  into  the 
clavicles  are  very  much  atrophied,  while  those  inserted  into  the  sternum  are 
somewhat  better  developed.  The  clavicular  portion  of  the  trapezius  has 
entirely  disappeared  on  the  left  side,  but  is  retained  on  the  right;  the  re- 
maining portions  of  the  trapezius  are  moderately  atrophied  on  both  sides. 
The  temperature  is  normal,  but  the  pulse  is  somewhat  accelerated  (ninety 
per  minute). 

The  left  arm  is  paralyzed;  the  deltoid  muscle  is  very  markedly  atro- 
phied, and  the  other  muscles  of  the  limb  are  also  considerably  reduced  in 
size. 

This  case  was  probably  due  to  a  chronic  inflammatory  process  which 
began  around  the  medulla,  compressing  the  bulbar  origin  of  the  spinal 
accessory  nerves,  and  then  spread  downward,  involving  the  spinal  roots 
of  origin  of  both  nerves,  and  then  also  affecting  the  origin  of  the  left  bra- 
chial plexus.  In  a  somewhat  similar  case  which  came  under  my  own 
notice,  and  which  was  due  to  an  injury  to  the  back  of  the  neck,  only  the 
spinal  roots  of  the  accessory  nerves  were  affected.  This  was  shown  by 
the  fact  that  the  patient  could  swallow  normally  and  the  muscles  of  the 
larynx  were  also  in  a  normal  condition.  Both  sterno-cleido-mastoids  were 
very  markedly  atrophied,  especially  those  portions  which  are  inserted  into 
the  clavicle;  the  sternal  bundles  of  fibres  were  also  considerably  smaller 
than  usual,  and  the  functions  of  the  muscles  were  correspondingly  lost. 
The  trapezii  were  also  very  much  atrophied,  and  the  power  of  elevating 
the  shoulders  diminished.  On  the  left  side,  which  was  more  severely  af- 
fected, the  scapula  was  lower  than  on  the  right  side,  its  posterior  border 
was  further  removed  from  the  spinal  column,  and  the  arm  could  not  be 
raised  to  the  vertical  position. 


Etiology. 

Paralysis  of  the  external  branch  of  the  nerve  is  not  very  infrequent, 
and  may  be  due  to  a  great  variety  of  causes;  paralysis  of  both  branches, 
however,  is  extremely  rare.  The  latter  variety  may  be  due  to  tumors  of 
the  posterior  cerebral  fossa,  exostoses  in  this  region,  or  exposure  to  a 
draught,  as  in  a  case  reported  by  Fraenkel.'  Paralysis  of  the  external 
branch  may  be  caused  by  blows  upon  the  neck,  wounds  of  various  kinds, 
exposure,  pressure  of  tumors  or  enlarged  glands,  and  neuritis.  It  also 
occurs  not  infrequently  during  the  course  of  progressive  muscular  atrophy. 
The  latter  disease  is  usually  regarded  as  a  central  process  (degeneration  of 
the  anterior  horns  of  the  spinal  column)  but  within  the  last  two  or  three 
years  considerable  doubt  has  been  cast  upon  this  view  of  its  pathology, 
and  well-known  authorities  are  accepting  the  doctrine  that  certa  n  forms, 
at  least,  must  be  regarded  as  peripheral  in  their  nature. 


Diagnosis  and  Prognosis. 

"When  the  velum  palati,  constrictors  of  the  pharynx  and  laryngeal 
muscles  of  phonation  are  paralyzed,  there  can  be  no  doubt  with  regard  to 
the  affected  nerve,  as  the  spinal  accessory  alone  supplies  these  parts  (with 


'  BerL  Klin.  Wschrft.  I.  1876. 


PEPaPHEllAL    PARALYSIS.  221 

the  exception  of  the  velum  palati  which  is  also  innervated  through  other 
paths).  Paralysis  of  the  sterno-cleido-mastoid  and  trapezius  muscles  is, 
however,  not  infrequently  mistaken  for  other  affections.  Paralysis  of 
the  sterno-mastoid  may  be  mistaken  for  torticollis  or  spasmodic  contrac- 
tion of  the  opposite  sterno-mastoid.  In  the  paralytic  affection,  however, 
the  head  can  be  easily  restored  to  its  natural  position  ;  in  addition,  the 
atrophy  of  the  muscle  is  usually  distinctly  perceptible  to  sight  as  well  as 
to  touch.  After  the  loss  of  power  has  lasted  for  a  long  time,  contracture 
of  the  opposite  muscle  may  occur,  and  a  correct  diagnosis  can  only  be 
made,  in  such  cases,  from  a  knowledge  of  the  previous  clinical  history. 
Paralysis  of  the  trapezius  is  most  apt  to  be  mistaken  for  contracture  of  the 
serratus  magnus,  as  this  will  also  interfere  with  the  elevation  of  the 
shoulder,  and  will  cause  the  scapula  to  be  depressed  and  removed  from  the 
spinal  column.  This  affection  can  be  readily  excluded  by  the  fact  that 
the  scapula  can  be  freely  moved  in  all  directions  by  the  hand  of  the  phy- 
sician. Inspection  of  the  parts  will  often,  also,  show  atrophy  of  the  mus- 
cle when  it  is  compared  with  the  opposite  side. 

Paralysis  of  the  internal  branch  of  the  nerve  usually  presents  a  very 
unfavorable  prognosis,  as  the  disease,  under  such  circumstances,  is  due  to 
intracranial  or  intraspinal  processes,  which  are  generally  of  an  incurable 
character.  Fraenkel's  patient,  in  whom  the  disease  was  due  to  rheumatic 
influences  (exposure  to  a  draught),  made  an  excellent  recovery. 

In  paralysis  of  the  external  branch  the  prognosis  varies  with  the  etiol- 
ogy. In  the  rheumatic  forms,  which  are  perhaps  the  most  frequent,  the 
chances  of  recovery  are  usually  good.  If  the  disease  has  lasted  for  a  long 
time,  however,  and  is  complicated  by  contracture  of  the  opposing  mus- 
cles, treatment  generally  proves  unavailing.  Those  cases  which  are  due 
to  injury,  neuritis,  or  the  pressure  of  enlarged  glands,  may  also  recover 
under  appropriate  treatment,  though  improvement  usually  occurs  slowly. 
When  the  paralysis  is  caused  by  compression  of  the  nerve  by  means  of  a 
tumor,  the  disease  may  be  relieved  if  the  tumor  is  situated  in  such  a  po- 
sition that  it  can  be  removed  by  surgical  measures. 


Treatment. 

In  all  cases,  electricity  constitutes  the  chief  and  sometimes  the  only 
plan  of  treatment.  Either  the  faradic  or  galvanic  current  may  be  em- 
ployed according  as  the  muscles  respond  to  one  or  the  other.  The  deep 
position  of  the  internal  branch  of  the  nerve  as  well  as  of  the  muscles  sup- 
plied by  it  (velum  palati,  pharynx,  and  larynx)  prevents  the  direct  appli- 
cation of  the  current  to  this  portion  of  the  nerve.  The  electrodes  are 
therefore  best  applied  upon  each  side  of  the  neck,  underneath  the  angle 
of  the  jaw  in  order  to  influence  the  muscles  of  the  velum  or  pharynx, 
and  upon  each  side  of  the  larynx  to  affect  the  muscles  of  the  latter. 
Faradization  of  the  sterno-mastoid  and  trapezius  can  be  readily  performed 
by  placing  one  electrode  over  the  origin  of  the  muscles  and  stroking  va- 
rious portions  of  the  bodies  of  the  muscles  with  the  other. 

In  applying  the  galvanic  current  to  the  sterno-mastoids  one  electrode 
should  be  placed  over  the  anterior  border  of  the  sterno-mastoid  about  an 
inch  below  the  lobe  of  the  ear,  and  the  other  at  the  lower  border;  to  gal- 
vanize the  trapezius,  one  electrode  is  placed  over  the  entrance  of  the 
nerve  into  the  muscle  (at  its  anterior  border,  half-way  between  the  occi- 
put and  clavicle),  and  the  other  over  that  portion   in  which   we  desire  to 


222  FUI^CTIOITAL    NERVOUS    DISEASES. 

produce  contraction.  When  we  have  reason  to  suspect  a  chronic  inflam- 
matory process  around  the  spinal  roots  of  origin  or  compression  of  the 
trunk  of  the  nerve  by  an  enlarged  gland,  counter-irritation  by  means  of 
fly-blisters  or  compound  tincture  of  iodine  may  prove  of  service.  Treat- 
ment is  usually  of  no  avail  when  the  paralysis  is  due  to  an  intracranial 
or  intraspinal  affection. 

When  contracture  of  the  opposite  sterno-mastoid,  or  of  the  serratus 
magnus  occurs,  improvement  may  perhaps  be  obtained  by  the  steady  use 
of  the  continuous  galvanic  current  through  the  contractured  muscles.  If 
no  relief  is  obtained  in  this  manner,  the  former  condition  may  some- 
times be  relieved  by  tenotomy  of  the  muscle,  and  the  subsequent  ap- 
plication of  an  orthopaedic  apparatus  to  the  head  in  order  to  prevent  a 
re-development  of  the  contracture. 


CHAPTER  YIIL 

PARALYSIS  OF  THE  HYPOGLOSSUS.i 
Clinical  History. 

Paralysis  of  the  tongue  is  not  an  infrequent  complication  of  the 
most  varied  central  diseases,  but  it  is  extremely  rare  as  a  peripheral 
aSection.  •  The  latter  may  be  due  to  the  pressure  of  tumors  growing 
from  the  medulla  (in  which  event  the  paralysis  may  be  bilateral),  to  a 
gunshot  wound  of  the  neck,  or  to  injury  of  the  nerve  during  various 
operations  in  this  region. 

In  unilateral  paralysis  of  the  tongue,  the  organ  when  protruded  from 
the  mouth,  is  deflected  toward  the  paralyzed  side  on  account  of  the  un- 
opposed action  of  the  normal  genio-glossus  muscle.  The  lateral  move- 
ments (toward  the  affected  side)  are  also  seriously  interfered  with  or 
completely  abolished.  After  the  paralysis  has  lasted  for  a  certain  length 
of  time,  the  affected  half  of  the  tongue  is  found  to  be  smaller  than  the 
opposite  side,  the  mucous  membrane  covering  it  looks  wrinkled,  and  fibril- 
lary contractions  may  be  visible  underneath  the  surface.  When  the 
paralysis  is  bilateral,  the  tongue  lies  in  the  floor  of  the  mouth  and  cannot 
be  moved  in  any  direction.  In  such  cases,  there  is  marked  disturbance 
of  the  functions  of  mastication  and  articulation.  The  former  is  inter- 
fered with  because  the  alimentary  bolus  cannot  be  readily  moved  from 
one  side  of  the  mouth  to  the  other  by  the  contractions  of  the  tongue 
muscles;  in  addition,  the  bolus  is  not  forced  properly  into  the  fauces  nor 
can  the  tongue  be  contracted  in  such  a  manner  as  to  separate  the  buccal 
cavity  from  that  of  the  pharynx;  in  the  act  of  deglutition,  therefore,  some 
of  the  food  will  regurgitate  into  the  mouth.  The  articulation  of  linouals 
may  be  entirely  abolished,  and  indeed  the  pronunciation  of  all  the  letters 
of  the  alphabet  is  usually  impaired  to  a  certain  extent.  These  disturb- 
ances are  naturally  greater  when  the  paralysis  is  bilateral  and  complete, 
and  in  such  cases  it  is  almost  impossible  to  understand  a  single  word 
uttered  by  the  patient. 

In  pure  examples  of  hypoglossal  paralysis,  there  are  no  disturbances 
of  taste  or  sensation  in  the  tongue. 

The  following  illustrative  case  is  taken  from  Weir  Mitchell's  work  on 
"Injuries  of  Nerves." 

"  Alonzo  B.  Rogers,  a  colored  lad,  aged  nineteen,  was  admitted  into 
the  Pennsylvania  Hospital,  November  24,  1871,  suffering  from  a  gunshot 
wound  of  the  neck.  The  ball  entered  the  left  side  of  the  neck,  one  and 
a  half  inch  behind  and  a  little  below  the  angle  of  the  jaw. 

'  This  nerve  is  distributed  to  all  of  the  muscles  in  the  infra-hyoid  region,  which 
depress  the  larynx  and  the  hyoid  bone  after  the  passage  of  the  alimentary  bolus 
through  the  pharynx ;  to  one  of  the  muscles  in  the  supra-hyoid  region,  the  genio- 
hyoid ;  to  most  of  the  muscles  which  move  the  tongue ;  and  to  the  muscular  fibres  of 
the  tongue  itself. 


224  FUNCTIOIS'AL    NERVOUS    DISEASES. 

"The  tongue  was  found  paralj^zed  on  the  left  side  as  regards  motion, 
but  not  sensation.  When  protruded,  it  turned  toward  the  left  or  wound- 
ed side,  and  could  not  be  held  against  the  upper  lip  without  the  aid  of 
the  under.  When  the  tip  was  pressed  against  the  roof  of  the  mouth,  it 
turned  toward  the  left  side.  The  patient  could  readily  press  the  tip 
against  any  point  on  the  right  side  of  the  mouth,  but  on  the  left  the  at- 
tempt was  attended  with  difficulty.  There  was  no  trouble  in  swallowing, 
but  the  patient  thought  he  could  not  articulate  as  distinctly  as  formerly. 

*'  Sensation  was  not  at  all  impaired.  Several  tests  were  made  at  dif- 
ferent times,  but  the  result  was  always  the  same.  The  right  side  of  the 
tongue  readily  responded  to  the  electric  current,  the  wounded  side  did 
not,  but  seemed  the  more  sensitive  under  the  current.  The  wounded 
side  of  the  tongue  was  notably  atrophied  before  the  patient  was  dis- 
charged. Several  attempts  were  made  to  find  the  bullet,  but  all  were 
unsuccessful.  The  wound  healed  without  any  difficulty,  and  the  patient 
left  December  12,  1871,  the  paralysis  continuing  unaltered." 


Diagnosis. 

The  diagnosis  of  paralysis  of  the  hypoglossus  is  readily  made  from  a 
mere  inspection  of  the  parts  upon  directing  the  patient  to  move  the 
tongue  in  various  directions.  It  is  sometimes  difficult  to  determine 
whether  the  paralysis  is  of  a  peripheral  or  central  nature.  The  most  im- 
portant points  in  this  respect  are  the  etiology  of  the  affection  (whether 
the  lesion  is  situated  in  the  course  of  the  nerve  after  its  exit  from  the 
skull)  and  the  implication  or  non-implication  of  other  nerves,  or  of  one 
or  more  limbs.  The  hypoglossi  are  affected  in  glosso-labio-laryngeal  pa- 
ralysis, but  this  disease  runs  such  a  typical  course  that  it  is  impossible  to 
make  a  mistake.  The  prognosis  is  usually  very  poor  as  regards  recov- 
ery of  the  paralysis.  When  the  disease  is  due  to  an  intracranial  process, 
whether  central  or  peripheral,  death  generally  results  on  account  of  the 
secondary  implication  of  other  of  the  bulbar  nerves. 


Treatment. 

Electrical  treatment  offers  the  only  chance  of  success,  that  current 
being  employed  to  which  tlie  muscles  respond  most  readily.  The  elec- 
trodes may  be  applied  directly  to  the  tongue  itself,  although  this  is  very 
inconvenient,  or  one  pole  is  placed  above  the  cornu  of  the  hyoid  bone 
above  which  the  hypoglossal  nerve  is  found  in  its  passage  to  the  tongue. 


CHAPTER  IX. 

PARALYSIS  OF  THE  SERRATUS  JLVGNUS. 

Clinical  Histoky, 

The  paralysis  of  this  muscle,  which  is  supplied  by  the  posterior  tho- 
racic nerve'  (external  respiratory  nerve  of  Bell)  is  extremely  inteiesting- 
on  account  of  the  peculiar  deformity  to  which  it  gives  rise.  Quite  an 
extensive  journal  literature  has  been  published  on  the  subject,  but  the 
question  as  to  the  real  cause  of  the  deformity  still  remains  undecided. 
The  paralysis  is  of  comparatively  rare  occurrence,  and  is  usually  unilat- 
eral, the  large  majority  of  cases  having  been  observed  upon  the  right 
side.  A  good  idea  of  the  usual  course  of  the  disease  may  be  formed 
from  the  following  history  of  a  case  under  my  observation  : 

Case  VI. — Annie  B.,  ret.  20  years,  a  servant  by  occupation;  no  his- 
tory of  traumatism,  though  she  has  been  in  tlie  habit  of  lifting  heavy 
weights;  no  history  of  syphilis.  About  four  months  ago  the  patient 
began  to  suffer  from  intense  darting  pains  along  the  outer  side  of  the 
riglit  arm;  these  continued  for  two  weeks  and  were  uniformly  worse  at 
night;  prior  to  the  appearance  of  the  pains  in  the  arm,  she  also  suffered 
intensely  in  the  anterior  part  of  the  right  thigh,  but  these  pains  only 
lasted  for  a  few  hours.  There  was  no  history  of  any  previous  exposure. 
After  the  neuralgic  pains  in  the  arm  had  lasted  for  two  weeks,  she  lost 
the  power  of  raising  the  arm  into  a  vertical  position.  Two  months  later, 
her  friends  noticed  that  the  shoulder-blade  projected  very  markedly  on 
the  right  side,  though  the  patient,  who  is  rather  stupid,  had  been  unaware 
of  this  fact. 

Upon  inspection,  the  patient's  hands  being  held  loosely  at  her  sides, 
very  little  deviation  from  the  normal  can  be  observed.  Upon  carefully' 
comparing  both  scapulae,  however,  the  inferior  angle  on  the  right  side  is 
found  to  be  somewhat  nearer  to  the  spinal  column  than  on  the  left;  the 
posterior  border  is  slightly  deflected,  the  upper  jiortion  being-  farther  re- 
moved from  the  spinal  column  than  the  lower  part;  the  lower  angle  of 
the  scapula  projects  very  slightly  from  the  wall  of  the  chest;  these  changes 
are  so  slight  that  they  can  only  be  noticed  on  close  observation.  When 
the  patient  endeavors  to  raise  the  arm,  the   peculiar  "  angel-wing "  de- 

'  The  posterior  thoracic  arises  from  the  fifth  and  sixth  cervical  nerves,  passes  down 
in  front  of  the  scalenus  medius  muscle,  and  then  along  the  lateral  aspect  of  the 
thorax  to  supply  the  serratus  magnus.  The  nerve  can  be  most  easily  reached  a  little 
above  the  clavicle  at  the  posterior  border  of  the  sterno-cleido-mastoid.  The  serratus 
magnus  "  arises  by  nine  fleshy  di.Liitatious  from  the  outer  surface  and  upper  border  of 
the  eight  upper  ribs  and  from  the  aponeurosis  covering  the  upper  intercostal  spaces, 
and  is  inserted  into  the  whole  length  of  the  inner  margin  of  the  posterior  border  of  the 
scapula. " 

15 


226  FUNCTIONAL    NERVOUS    DISEASES. 

formity  starts  out  in  bold  relief,  and  the  arm  can  only  be  raised  to  the 
horizontal  position.  At  the  same  time  that  this  is  done,  the  posterior 
border  of  the  scapula  begins  to  move  away  from  the  walls  of  the  chest, 
and  when  the  arm  has  been  raised  to  the  horizontal,  the  separation  of  the 
scapula  is  so  great  that  almost  the  entire  fist  can  be  introduced  between 
the  anterior  surface  of  the  bone  and  the  chest-walls.  The  faradic  reac- 
tion of  the  paralyzed  muscle  was  entirely  lost  in  the  beginning,  and  the 
galvanic  excitability  was  very  markedly  diminished.  The  latter  current 
%vas  steadily  employed,  and  the  patient  advised  to  exercise  the  muscle. 
Within  two  months  recovery  had  made  considerable  progress,  and  when 
the  patient  ceased  her  attendance  at  the  clinic,  the  cure  was  practically 
complete.  She  again  called,  after  an  interval  of  a  couple  of  months,  to 
report  herself  entirely  well. 

The  paralysis  is  very  often  preceded  by  neuralgic  pains  in  the  arm  or 
shoulder,  and  sometimes  by  anesthesia  or  hyperesthesia  in  these  regions. 
It  develops  slowly,  as  a  rule,  though  such  a  long  interval  as  was  appar- 
ently present  in  the  case  reported  above,  between  the  beginning  of  the 
affection  (neuralgic  pain)  and  the  production  of  the  paralysis,  is  very  un- 
usual. Not  infrequently  other  muscles  are  also  affected,  such  as  the  in- 
fraspinatus, supraspinatus,  trapezius,  levator  anguli  scapulae.  The  reason 
for  this  combination  will  become  evident  when  we  consider  the  etiology 
of  the  disease. 

In  lon^-  standing  cases,  atrophy  of  the  muscle  can  be  detected  if  we 
direct  the  patient  to  raise  both  arms,  and  carefully  compare  the  appear- 
ances presented  at  the  upper  and  lateral  portions  of  the  thorax.  If  the 
panniculus  adiposus  is  not  too  thick,  the  digitations  of  the  muscle  at 
their  origin  from  the  ribs  will  be  found  much  smaller  on  the  affected 
side.  The  electrical  reactions  to  both  currents  are  simply  diminished  in 
the  majority  of  cases,  though  the  degeneration-reaction  has  also  been 
observed. 

There  ^s  a  difference  of  opinion  with  regard  to  the  position  of  the 
scapula  when  the  arm  is  held  loosely  at  the  side.  Some  maintain  that  no 
deformity  whatever  is  perceptible  under  these  circumstances,  while  the 
majority  of  observers  mention  the  appearances  noted  in  the  case  which  I 
have  reported  above,  viz.,  a  closer  approximation  of  the  lower  angle  of 
the  scapula  to  the  spinal  column,  a  change  in  the  direction  of  the  posterior 
border  of  the  scapula  from  vertical  to  upward  and  outward,  and  slight 
separation  of  the  lower  angle  of  the  bone  from  the  walls  of  the  thorax. 
In  the  few  cases  which  have  come  under  my  notice,  these  appearances 
have  always  been  presented.  According  to  Berger,  these  changes  in  the 
position  of  the  bone  are  due  to  the  unopposed  action  of  the  trapezius,  the 
levator  anguli  scapulas  and  the  rhomboidei  muscles.  The  angel-wing  de- 
formity, which  is  produced  when  the  attempt  is  made  to  raise  the  arm,  is 
very  difficult  of  explanation.  The  simplest  view  appears  to  us  to  be  that 
of  Duchenne,  which  has  recently  been  revived  by  Lewinski.'  According 
to  these  authors  it  is  merely  the  result  of  the  contraction  of  the  deltoid. 
When  the  arm  has  been  brought  into  a  horizontal  plane,  it  cannot  be 
raised  any  further  by  the  unassisted  efforts  of  the  deltoid.  This  muscle 
will  therefore  exert  traction  upon  the  scapula,  which  is  no  longer  held 
against  the  thorax  by  the  serratus  magnus;  the  mere  contraction  of  those 

'  Arch.  £.  Path.  Anat.,  1878,  pp.  473-500. 


PEKIPnEKAL    PARALYSIS.  227 

fibres  of  the  deltoid  which  take  their  origin  from  the  spine  of  the  scapula 
(the  insertion  of  which  into  the  humerus  now  forms  the poi7it  cVappui)  will 
naturally  cause  the  posterior  border  of  the  scapula  to  revolve  outward 
and  thus  become  separated  from  the  chest-walls. 

The  inability  to  raise  the  arm  to  the  vertical  position  also  requires  a 
few  words  of  explanation.  The  serratus  magnus  muscle  is  inserted  into 
the  entire  posterior  border  of  the  scapula;  when  the  muscle  contracts,  it 
therefore  pulls  upon  the  bone  and,  as  the  lower  angle  of  the  bone  is  not 
held  so  firmly  in  position  by  muscular  action  as  the  upper,  the  contraction 
of  the  scapula  causes  the  inferior  angle  to  turn  forward  and  upward,  and 
thus,  in  some  sort,  to  revolve  around  the  superior  posterior  angle.  This 
causes  the  anterior  angle  of  the  bone  to  move  upward,  and  the  humerus, 
which  is  firmly  held  against  the  latter  by  the  contraction  of  the  deltoid, 
is  thus  pushed  upward  into  the  vertical  position.  This  action  of  the  ser- 
ratus magnus  may  be  readily  imitated  in  cases  in  which  the  muscle  is 
paralyzed.  The  patient  is  directed  to  hold  the  arm  steadily  in  the  hori- 
zontal position,  and  the  physician  then  makes  forcible  pressure  forward 
upon  the  prominent  inferior  angle  of  the  scapula;  in  proportion  as  the 
bone  is  pushed  forward,  the  arm  will  be  found  to  rise  and  will  finally 
reach  the  vertical  position. 

Erb  mentions  a  case  in  which  a  patient,  suffering  from  this  affection, 
could  nevertheless  raise  the  arm  to  the  vertical  position  by  bending  the 
chest  backward  and  then  swinging  the  humerus  forcibly  forward;  its 
inertia  carried  it  past  the  horizontal  into  the  vertical  position,  a  luxation 
of  the  head  of  the  humerus  downward  being  produced  at  the  same  time. 
An  exactly  similar  case  has  fallen  under  my  own  observation. 

Baeumler '  reports  a  case  in  which  the  arm  could  be  almost  complete- 
ly raised  into  the  vertical  position  by  gradual  muscular  contraction.  He 
found  that  the  deltoid,  supraspinatus  and  infraspinatus  muscles  were 
considerably  hypertrophied,  and  by  their  contraction  fixed  the  arm  firmly 
at  a  right  angle  to  the  axis  of  the  scapula;  the  trapezius  was  then  brought 
into  action,  and  by  its  contraction  tilted  up  the  scapula  sufficientlv  to 
raise  the  arm  almost  into  a  vertical  position. 

In  exceptional  instances  the  paralysis  is  bilateral,  though  such  cases 
Are  usually  of  a  central,  not  peripheral,  origin.  A  case  of  this  kind  has 
come  under  my  notice  in  which  the  paralysis  of  both  muscles  was  un- 
doubtedly due  to  a  syphilitic  lesion  of  the  posterior  thoracic  nerves.  In 
the  patient  in  question  the  paralysis  of  one  muscle  was  well  advanced 
toward  recovery  when  the  other  became  involved.  Under  the  use  of 
anti-syphilitic  remedies,  the  affection  was  entirely  relieved. 

The  nerve  supplying  the  serratus  muscle  was  called  the  external  re- 
spiratory nerve  by  Bell,  under  the  erroneous  impression  that  the  muscle 
was  actively  engaged  in  ordinary  inspiration.  This  notion  is  refuted  by 
the  case  to  which  we  have  just  referred,  in  which  no  disturbance  of  respi- 
ration could  be  detected,  although  both  muscles  were  completely  paralyzed. 


Etiology. 

The  most  frequent  causes  of  the  disease  are  traumatism  and  over- 
work. For  this  reason  we  find  that  the  right  side  is  almost  invariably 
affected,  and    that    it    occurs  much   more    frequently  in    males    than  in 

'  Deutsches  Archiv  f.  klin.  Med.  1880,  p.  305. 


228 


FUNCTIONAL    NE.llVOUS    DISEASES. 


females.  The  nerve  may  be  injured  by  falls  and  blows  upon  the  shoulder^ 
by  direct  division  of  the  nerve  by  gunshot  or  other  wounds,  by  compres- 
sion from  bearing  heavy  weights  upon  the  shoulder.  It  may  also,  though 
rarely,  be  due  to  rheumatic  influences  (sitting  in  a  draught,  lying  u})on 
the  affected  side  when  exposed  to  wet,  etc.).  As  in  the  case  of  bilateral 
paralysis,  which  we  have  mentioned  above,  the  disease  may  be  due  to 
syphilitic  lesions.  This  appears  to  me,  however,  to  be  a  unique  obser- 
vation, as  I  have  not  found,  in  the  literature  of  the  affection,  any  report 
of  a  similar  causation. 

Berger,  and  a  few  other  authors,  have  also  reported  paralysis  of  the 
serratus  magnus  as  one  of  the  sequences  of  typhoid  fever.  Finally,  this 
muscle  not  infrequently  becomes  paralyzed  during  the  course  of  progres- 
sive muscular  atrophy,  and  it  is  especially  in  this  affection  that  both  sides 
are  apt  to  become  involved. 


Diagnosis  and  Prognosis. 

The  diagnosis  of  paralysis  of  the  serratus  magnus  muscle  is  made 
with  extreme  ease.  It  is  merely  necessary  to  direct  the  patient  to  raise 
the    arm,  when   the    peculiar    deformity   (angel's  wing)  which  we    have 


Posterior  thoracic  nerve. 


Intercostal  nerves. 


'-^^Serratus  magnus. 
Latissimus  dorsi 


Intercostal  nerves. 


Transversalis. 


Fig.  2. — Motor  points  of  the  trunk. 


described,  immeJliately  becomes  apparent  and  cannot  possibly  be  mis- 
taken as  the  result  of  any  other  affection.  It  should  be  remembered, 
also,  that  there  is  very  little  change  in  the  position  of  the  scapula  during 
rest.  The  other  muscles  of  the  scapula  and  shoulder  should  also  be  care- 
fully examined   as  we  not   infrequently  find   that  the  same  cause  which 


PERIPHERAL    PARALYSIS.  229 

has  produced  the  affection   under  consideration,  has  also   given  rise  to 
paralysis  of  some  of  the  other  adjacent  muscles. 

It  is  sometimes  difficult  to  make  a  differential  diagnosis  between  the 
peripheral  form  of  the  disease  and  that  occurring  in  progressive  muscular 
atrophy.  In  exceptional  cases  the  latter  disease  begins  in  the  serratus 
magnus,  and  the  diagnosis  then  becomes  very  puzzling.  In  the  peri- 
pheral form,  however,  the  affection  is  usually  preceded  by  darting  pains, 
and  sometimes  by  anresthesia  or  hypenesthesia,  in  the  neighborhood  of 
the  shoulder.  In  addition,  the  faradic  excitability  is  usually  normal  (when 
compared  with  the  number  of  muscular  fibres  which  are  still  retained)  in 
progressive  muscular  atrophy  ;  in  paralysis  of  peripheral  origin  it  is 
diminisiied  or  lost.  When  numerous  other  muscles  of  the  body  are 
paralyzed,  the  diagnosis  of  progressive  muscular  atrojjhy  is  rendered 
very  easy. 

Treatment. 

The  treatment  of  paralysis  of  the  serratus  magnus  muscle  is  very 
simple  indeed,  consisting  merely  in  the  administration  of  an  electrical 
current  to  the  nerve  or  muscle,  according  as  one  or  the  other  reacts. 
One  electrode  is  pressed  firmly  behind  the  sterno-cleido-mastoid  muscle, 
immediately  above  its  insertion  into  the  clavicle,  as  the  nerve  is  most 
accessible  in  this  region  after  it  passes  through  the  scalenus  medius 
(Fig.  2.).  The  other  electrode  is  placed  along  the  course  of  the  nerve 
in  the  middle  of  the  axillary  space  upon  the  chest-walls,  or  upon  the 
origin  of  the  muscle  from  the  ribs.  When  no  response  could  be  obtained 
in  this  manner,  I  have  sometimes  succeeded  in  producing  contractions  by 
placing  one  electrode  upon  the  origin  of  the  muscle,  then  directing  the 
patient  to  elevate  the  arm,  and  when  the  angel-wing  deformity  had  thus 
been  produced,  pressing  the  other  electrode  firmly  between  the  chest- 
walls  and  the  anterior  surface  of  the  scapula,  and  thus  passing  the  cur- 
rent directly  through  the  muscle  itself.  When  the  affection  is  attended 
with  considerable  pain  in  some  of  the  cutaneous  filaments  supplying  the 
shoulder  and  arm,  great  relief  may  sometimes  be  procured  by  applying 
counter-irritation  over  the  course  of  the  nerves  ^i  the  brachial  plexus. 
It  is  rarely  necessary  to  resort  to  the  administration  of  morphine  for 
this  purpose. 


CHAPTEE   X. 

PAKALYSIS  OF   THE   PHRENIC   NERVE. 
Clixical  History. 

Peripheral  paralysis  of  this  nerve,  which  is  distributed  to  the  dia- 
phragm, is  an  extremely  rare  affection;  it  may  be  due  either  to  rheumatic 
causes  or  to  wounds  of  the  nerve  in  the  neck.  The  diaphragm  some- 
times loses  its  contractile  power  in  severe  cases  of  pleurisy  or  perito- 
nitis, but  this  is  due  to  a  spread  of  the  inflammation  from  the  serous 
membranes  to  the  structure  of  the  muscle  itself,  and  cannot  therefore  be 
regarded  as  a  true  paralysis.  Paralysis  and  atrophy  of  the  diaphragm 
also  occur  in  the  last  stages  of  progressive  muscular  atrophy,  and  its  de- 
velopment is  then  ominous  of  approaching  death. 

The  symptoms  of  this  form  of  paralysis  are  very  characteristic. 
When  the  patient  makes  an  inspiration,  the  epigastrium  sinks  in  instead  of 
becoming  more  prominent;  this  is  due  to  the  fact  that  the  capacity  of  the 
tliorax  is  increased  by  the  contraction  of  the  intercostal  muscles  and  the 
diaphragm  is  therofore  forced  upward  to  fill  up  the  space.  During  tlie 
act  of  expiration,  the  opposite  phenomenon  is  observed,  the  epigastrium 
being  elevated.  During  rest,  the  patient  experiences  no  difficulty  in  res- 
piration, but  as  soon  as  he  attempts  to  perform  any  active  exercise,  the 
breathing  becomes  labored  and  the  dyspnoea  soon  becomes  extreme,  the 
auxiliary  muscles  of  respiration  being  called  into  play.  All  reflex  acts 
whose  performance  requires  the  contraction  of  the  diaphragm,  such  as 
coughing,  sneezing,  etc.,  are  interfered  with  or  entirely  abolished,  and  in 
this  very  fact  lies  one  of  the  chief  dangers  of  the  disease.  Thus  a  patient 
suffering  from  ordinary  bronchitis,  whose  diaphragm  is  paralyzed  at  the 
same  time,  will  be  unable  to  expectorate  the  secretion  of  the  bronchial 
tubes,  and  is  therefore  placed  in  imminent  danger  of  death  from  suffoca- 
tion. 

The  diagnosis  of  this  affection  is  very  simple,  as  the  sinking  of  the 
epigastrium  during  inspiration,  and  its  protrusion  on  expiration  are 
pathognomonic  of  this  form  of  paralysis.  The  cause  of  the  disease  is 
also  readily  determined  from  the  clinical  history  of  the  case. 

Treatment. 

The  treatment  consists  almost  solely  of  faradization  or  galvanization 
of  the  phrenic  nerve  or  diaphragm.  This  is  effected  by  pressing  one  elec- 
trode deep  into  the  neck  at  the  anterior  border  of  the  sterno-cleido-mas- 
toid  immediately  above  the  sternum,  and  the  other  along  the  insertion  of 
the  diaphragm  into  the  costal  cartilages  of  the  false  ribs.  In  almost  all 
cases  the  paralyzed  muscle  reacts  well  to  both  currents,  but  one  case  has 
been  reported  in  which  the  electrical  excitability  of  the  muscle  was  di- 
minished. If  the  paralysis  is  due  to  some  inflammatory  lesion  in  the  neck 
along  the  course  of  the  nerves,  counter-irritation  is  indicated.  It  is  im- 
portant in  these  cases  to  keep  the  bowels  regular  and.  avoid  the  develop- 
ment of  tympanites,  as  very  slight  disturbances  of  this  nature  will  inter- 
fere seriously  with  the  proper  performance  of  respiration. 


CHAPTER  XL 

PARALYSIS  OF  THE  NERVES  OF  THE  ARM. 

Paralysis  of  the  Circumflex. 

Clinical  History. 

This  nerve  supplies  the  deltoid  and  teres  minor  muscles,  ajid  sends  sen- 
sory filaments  to  the  integument  of  the  shoulder;  it  is  very  frequently 
paralyzed  either  alone  or  in  combination  with  other  nerves.  Tiie  deltoid 
raises  the  arm  from  the  thorax  to  the  horizontal  position;  the  teres  minor 
assists  in  rotating  the  arm  outward.  The  paralysis  may  develop  suddenly 
or  very  gradually,  according  to  its  causation.  When  it  is  due  to  neuritis, 
it  is  frequently  accompanied  by  a  feeling  of  numbness  or  shooting  pains 
in  the  shoulder;  these  sensory  disturbances  are  often  combined  with  an- 
a?sthesia  of  the  integument  in  this  re^aion.  The  paralytic  symptoms 
simply  consist  of  the  inability  of  the  patient  to  raise  the  arm  from  the 
side;  the  action  of  the  teres  minor  is  so  slight,  and  is  so  thoroughlv  com- 
pensated by  other  muscles,  that  we  can  disregard  it  altogether.  If  the 
lesion  of  the  nerve  is  a  severe  one,  atrophy  of  the  muscles  develops  more 
or  less  rapidly.  "When  this  occurs,  the  diminished  rotundity  of  the  shoul- 
der is  readily  perceptible,  and  in  extreme  cases  the  finger  may  be  pressed 
between  the  humerus  and  the  glenoid  cavity  of  the  scapula.  In  such  cases 
the  arm  is  somewhat  longer  than  its  fellow,  because  the  tonicity  of  the 
deltoid,  which  serves  to  hold  the  head  of  the  humerus  snugly  against  the 
scapula,  is  lost,  and  the  arm  therefore  droops  more  than  in  the  normal 
condition.  The  electrical  reactions  vary  considerably  ;  only  in  the  mild- 
est cases  are  they  normal.  In  the  majority  of  cases  which  have  come 
under  m}''  observation,  the  excitability  of  the  muscle  was  simply  dimin- 
ished to  both  currents;  in  rarer  instances,  well-marked  degeneration- 
reaction  is  observed.  I  have  noticed  with  special  frequency  in  this  form 
of  paralysis  that  the  electrical  excitability  of  the  muscle  may  still  be  con- 
siderably lowered,  even  after  it  reacts  with  normal  promptitude  to  the 
stimulus  of  the  will. 

Etiology. 

Traumatism  constitutes  probably  one  of  the  most  frequent  causes  of 
deltoid  paralysis.  The  injury  may  be  of  various  kinds,  such  as  a  fall  upon 
the  shoulder,  a  blow  with  a  blunt  instrument  (in  one  of  my  patients  the 
paralysis  was  caused  by  a  blow  with  the  fist,  which  struck  immediately 
above  the  clavicle  over  the  course  of  the  brachial  plexus),  pressure  from 
a  dislocated  or  fractured  humerus,  pressure  from  sleeping  on  the  shoulder, 
or  the  injury  produced  in  version  by  the  arm  during  delivery,  an  example 
of  which  has  come  under  my  notice.  In  some  of  these  cases,  inflamma- 
tion of  the  circumflex  nerve  may  be  produced,  and,  as  I  have  noticed   in 


232  FUNCTIONAL    NERVOUS    DISEASES. 

several  cases,  the  neuritis  may  spread  upward  to  the  brachial  plexus,  and 
thus  involv^e  other  nerves  in  the  paralysis.  Rheumatic  influences,  such 
as  exposure,  also  constitute  a  not  very  infrequent  cause  of  deltoid  par- 
alysis; it  may  also  be  produced  by  overstretching  of  the  muscle.  A 
few  cases  have  been  repoited  in  which  the  affection  followed  certain  of 
the  infectious  diseases,  such  as  scarlet  fever,  small-pox,  etc.  Finally, 
deltoid  paralysis  (usually  bilateral)  may  usher  in  an  attack  of  lead-palsy, 
and  may  be  restricted  to  these  muscles,  though  it  generally  spreads,  after 
a  short  interval,  to  the  extensors  of  the  forearm.  On  account  of  the  in- 
teresting character  of  this  modification  of  lead-palsy,  I  will  give  a  brief 
abstract  of  the  history  of  a  patient  now  under  my  observation  in  Ran- 
dall's Island  Hospital  : 

Case  VIII. — Laurence  Clooney,  ast.  37  years,  house  painter;  entered 
the  hospital.  May  13, 1880.  He  has  worked  at  his  trade  for  eighteen  years; 
two  years  ago  he  had  an  attack  of  lead  colic.  The  patient  continued 
well  since  then  until  January  6,  1880,  when  he  suddenly  noticed  while 
at  work  that  he  could  not  lift  his  arms  from  the  side  (paralysis  of  the 
deltoids).  Two  days  afterward  he  again  had  an  attack  of  colic,  and  pains 
began  to  be  felt  in  both  arms.  He  kept  on  working  until  April  25th, 
when,  on  attempting  to  wash  his  hands,  he  found  that  they  were  also 
paralyzed;  two  days  later  an  attack  of  colic  occurred,  and  five  days  later 
another  attack. 

Present  condition. — The  patient  has  a  sallow-complexion  ;  he  thinks 
he  has  lost  flesh  ;  marked  blue  line  on  the  gums.  No  loss  of  sensibility 
can  be  discovered  in  any  part  of  the  body.  The  deltoid  muscles  are  com- 
pletely paralyzed  (he  is  unable  to  lift  the  arm  from  the  side  of  the  chest) 
and  are  markedly  atrophied,  the  right  to  a  greater  extent  than  the  left;  he 
presents  weakness  with  some  atrophy  of  the  biceps  ;  the  triceps  is  not 
appreciably  affected.  Paralysis  of  the  extensors  of  the  wrist,  more  marked 
on  the  right  side,  with  very  considerable  atrophy  of  these  muscles  is  also 
noticeable.  The  supinator  longus  of  the  right  arm  is  paretic  and  small- 
er in  size  than  the  left.  All  the  affected  muscles  present  a  diminished 
react  on  to  the  faradic  current. 


Diagnosis. 

The  diagnosis  of  deltoid  paralysis  is  very  readily  made  from  the  loss 
of  function  of  the  muscle.  In  two  of  my  cases,  occurring  in  a  child  (in 
whom  all  forms  of  paralysis  are  detected  with  much  greater  difficulty  than 
in  the  adult),  a  diagnosis  had  been  made  of  dislocation  of  the  humerus. 
This  mistake  is  readily  obviated  by  placing  the  hand  of  the  affected  side 
over  the  opposite  shoulder.  In  paralysis  of  the  deltoid,  the  elbow  can 
be  brought  in  apposition  with  the  chest,  while  the  arm  is  in  this  position  ; 
in  dislocation  of  the  humerus  this  cannot  be  done.  Another  patient 
was  referred  to  me  by  a  surgeon,  who  thought  the  case  was  one  of  del- 
toid paralysis.  A  very  slight  examination,  however,  served  to  show 
that  the  patient  was  suffering  from  fracture  of  the  humerus,  A  mistake 
of  this  kind  can  only  result  from  sheer  carelessness. 

In  rare  instances  infantile  paralysis  affects  the  deltoid  without  involv- 
ing any  other  muscles,  and  it  may  then  be  very  difficult  to  decide  whether 
the  paralysis  is  of  a  pw ipheral  or  central  nature.     The  distinguishing  fea- 


PEPJPIIEUAL    PARALYSIS.  233 

tures  of  the  latter  are  :  its  occurrence  in  childhood,  the  frequent  develop- 
ment of  febrile  symptoms  prior  to  the  paralysis,  the  rapid  atrophy  of  the 
muscle,  the  absence  of  any  determinable  cause,  and  the  almost  absolutely 
unfavorable  prognosis  as  regards  recovery  from  the  paralysis. 


Tkeatment. 

Electricity  furnishes  our  chief  resource  in  the  treatment  of  paralysis 
of  this  nerve.  As  a  general  thing  that  current  should  be  employed  to 
which  the  muscle  responds  most  readily,  but  it  is  found,  in  exceptional 
cases,  that  recovery  occurs  under  the  continued  employment  of  faradism 
altliough  the  paralyzed  muscles  do  not  react  to  this  current.  In  apply- 
ing electricity  to  the  deltoid,  one  electrode  should  be  placed  upon  its  ante- 
rior fibres  below  the  clavicle  and  the  other  slowly  moved  across  the  body 
of  the  muscle.  This  method  is  applicable  to  both  currents,  and  does  not 
require  the  use  of  the  interrupting  handle.  When,  the  paralysis  is  due 
to  neuritis,  which  is  still  present  in  an  active  stage,  it  is  doubtful  whether 
electrization  of  the  muscle  itself  is  attended  with  much  benefit.  In  such 
cases  it  is  well  to  pass  the  uninterrupted  constant  current  through  the 
nerve,  one  electrode  being  placed  upon  the  brachial  plexus  in  the  neck, 
and  the  other  near  the  insertion  of  the  muscle  into  tlie  humerus.  There 
appears  to  be  a  special  tendency  for  neuritis  of  the  circumflex  to  spread 
upward  and  secondarily  involve  other  branches  of  the  brachial  plexus. 
Counter-irritation  (in  the  form  of  fly-blisters)  is  useful  in  combating  this 
tendency;  the  blisters  should  be  applied  upon  any  painful  spots  which 
may  be  present  in  the  muscle,  and  also  along  the  course  of  the  plexus  in 
the  root  of  the  neck  (at  the  anterior  border  of  the  trapezius). 

When  the  paralysis  is  due  to  pressure  upon  the  nerve  from  disloca- 
tion or  fracture  of  the  humerus,  etc.,  the  appropriate  surgical  measures 
must,  of  course,  be  adopted. 


Paralysis  of  the  Musculo-Cutaneous  Nerve. 
Clinical  History. 

This  nerve  supplies  the  biceps,  brachialis  anticus,  and  coraco-brachialis 
muscles,  and  is  also  distributed  to  the  integument  of  the  outer  and  an- 
terior aspects  of  the  forearm  and  ball  of  the  thumb,  and  the  lower  third 
of  the  posterior  surface  of  the  forearm.  It  is  very  rarely  paralyzed  after 
leaving  the  brachial  plexus,  as  it  is  situated  very  deeply  and  therefore 
not  liable  to  injury.  Even  when  a  trauma  affects  the  plexus,  this  nerve 
usually  escapes  on  account  of  its  protected  position.  I  have  a  case  un- 
der observation,  however,  at  present,  in  which  this  nerve  alone  became 
paralyzed  while  the  individual  was  on  a  drunken  debauch  ;  the  patient 
is  unable  to  give  an  account  of  the  nature  of  the  accident,  but  it  probably 
occurred  from  injury  of  some  kind. 

The  symptoms  of  this  form  of  paralysis  consist  merely  of  partial  loss 
of  the  power  of  flexing  the  forearm  upon  the  arm  and  loss  of  sensation 
on  the  anterior  and  posterior  aspects  of  the  outer  side  of  the  forearm. 
Flexion  of  the  forearm  is  not  entirely  lost   because  the  supinator  longus 


234 


FITNCTIOKAL    NERVOUS    DISEASES. 


acts  as  flexor  as  well  as  supinator.  As  this  disease  usually  forms  part 
of  paralysis  of  the  entire  brachial  plexus,  its  etiology  and  treatment  are 
similar  to  those  of  the  latter.      (Fig.  3.) 


Paralysis  of  the  Median  Nerve. 
Clinical  History. 

This  nerve  supplies  the  deep  and  superficial  flexors,  the  flexor  carpi 
radialis,  the  muscles  of  the  ball  of  the  thumb  with  the  exception  of  the 
adductor  poilicis,  both  pronators,  and  the  first  three  lumbricales;  it  is 
also  distributed  to  the  integument  of  the  anterior  surface  of  the  thumb, 
the  first  two  fingers  and  outer  half  of  the  ring  finger,  and  the  dorsal  aspect 
of  the  second  and  third  phalanges  of  the  index  and  middle  fingers  and 
outer  half  of  the  ring  finger. 

Paralysis  of  the  deep  and  superficial  flexors  causes  loss  of  the  power 
of  flexion  of  the  second  and  third  phalanges;  it  does  not  affect  the  first 


JIusculo-cutaneous  nerve.         Biceps. 


Mnscnlo-cutaneous  Branch  to    Median    BrachialiB    Ulnar  nerve, 

nerve.  long  head    nerve.        antions. 

of  triceps. 

Fig.  3. — Motor  points  of  inner  aspect  of  arm. 


phalanges  as  they  are  flexed  by  the  contraction  of  the  interossei  mus- 
cles, which,  at  the  same  time,  produce  extension  of  the  second  and  third 
phalanges.  When  the  paralysis  of  the  flexor  muscles  is  complete  and 
long-continued,  the  unopposed  action  of  the  interossei  may  permanently 
cause  flexion  of  the  first  phalanges  and  hyperextension  of  the  second  and 
third.  Paralysis  of  the  pronators  of  the  forearm  (which  are  also  supplied 
by  the  median  nerve)  interfere  with  pronation  to  a  certain  extent,  though 
not  completely,  as  this  function  is  performed  in  part  by  the  supinator 
longus,  when  the  forearm  is  flexed  upon  the  arm. 

Flexion  of  the  wrist  cannot  be  performed  normally,  on  account  of  the 
paralysis  of  the  flexor  carpi   radialis.      The   paralysis  of   the  muscles  of 


PERIPHERAL    PARALYSIS.  235 

the  thumb,  with  the  exception  of  the  adductor  pollicis,  causes  loss  of  the 
power  of  touching  the  tips  of  the  fingers  with  the  thumb  and  of  pressing 
the  thumb  firmly  against  the  forefinger.  The  unopposed  action  of  tlie 
extensor  longus  pollicis  produces  hyperextension  of  the  thumb,  and  at 
the  same  time  cause  a  disappearance  of  the  natural  projection  of  the 
ball  of  the  thumb  anteriorly,  thus  flattening  the  entire  anterior  surface 
of  the  hand. 

Where  the  entire  trunk  of  the  nerve  is  wounded,  sensation  may  be 
lost  on  the  anterior  surface  of  the  thumb,  the  first  two  fingers,  outer  half 
of  the  ring  finger,  the  dorsal  aspect  of  the  second  and  third  phalanges 
of  the  index  and  middle  fingers,  and  the  outer  half  of  the  ring  finger. 
The  distribution  of  the  sensory  disturbances,  is  however,  subject  to  very 
great  modification,  and  indeed  Richet  has  reported  a  case  (to  which  we 
have  previously  referred)  in  which  division  of  the  median  nerve  was  not 
followed  by  any  loss  of  sensation  in  the  hand.  This  peculiar  phenome- 
non is  explained  by  the  presence  of  Arloing  and  Tripier's  recuz-rent  sen- 
sory fibres,  which  pass  from  the  ulnar  and  radial  nerves  to  the  median, 
and  to  Avhich  reference  has  been  so  frequently  made  in  the  article  on 
neuralgia.  Various  trophic  disturbances,  which  are  entirely  similar  in  all 
respects  to  those  which  have  been  mentioned  as  occurring  in  traumatic 
neuralgia  of  the  upper  limbs,  are  also  observed  in  severe  paralysis  of  this 
nerve. 

Etiology. 

Median  paralysis  is  due  to  a  great  variety  of  causes,  especially  to 
traumatism,  including  gunshot  wounds,  incised  wounds  with  a  knife, 
pieces  of  glass,  etc.,  blows  with  a  club;  to  pressure  from  tumors  of  va- 
rious kinds,  from  excessive  development  of  callus  after  fracture,  from  the 
bands  of  a  strait-jacket  when  drawn  too  tightly;  from  neuritis  in  conse- 
quence of  exposure,  or  as  a  sequel  of  certain  infectious  diseases. 

This  nerve  is,  however,  rarely  paralyzed  separately  and,  indeed,  it  is 
unf requently  met  with  even  in  combination  with  paralysis  of  other  nerves 
of  the  arm. 

Treatment. 

The  remarks  made  on  the  treatment  of  deltoid  paralysis  also  hold 
good  with  reference  to  this  form  of  jDaralysis.  In  applying  electricity  to 
the  median  nerve,  one  electrode  is  placed  in  the  fold  of  the  elbow  to  the 
inside  of  the  median  line  (vide  Fig.  4)  and  the  other  electrode  is  ap- 
plied above  the  wrist  directly  in  the  median  line.  The  muscles  of  the 
ball  of  the  thumb  and  the  lumbricales  may  be  electrized  through  the  nerve 
by  placing  one  electrode  over  the  lower  portion  of  the  nerve  above  the 
wrist,  and  the  other  (a  small  olive-pointed  electrode)  upon  the  motor 
points  shown  in  Fig.  4,  or  the  current  may  be  passed  through  the 
muscles  (usually  more  effectual),  the  olive-pointed  electrode  being  re- 
tained in  the  position  just  described,  and  the  other  being  placed  on  the 
dorsum  of  the  hand. 

Surgical  measures  frequently  prove  of  decided  relief  when  the  paral- 
ysis is  due  to  compression  of  the  nerve  by  an  old  cicatrix,  a  foreign  body 
in  a  wound,  etc.  These  cases  are  often  attended  with  considerable  pain, 
which  is  sometimes  so  severe  as  to  necessitate  the  hypodermic  adminis- 
tration of  morphine. 


236 


FUNCTIONAL    NEEVOUS    DISEASES. 


Paealysis  op  the  Ulnar  Nerte. 

Clinical  History. 

The  motor  fibres  of  the  ulnar  nerve  are  distributed  to  the  flexor  carpi 
ulnaris  and  a  portion  of  the  flexor  digitorum  profundus,  the  interossei 
(both  pahuar  and  dorsal),  first  two  lumbricales,  the  adductor  pollicis  and 
the  muscles  of  the  hypothenar  eminence;  the  sensory  fibres  ai"e  distribu- 
ted to  the  ulnar  third  of  the  palm  of  the  hand,  the  flexor  aspect  of  the 


Median  nerve. . . 
Palmaris  longis. 


Flexor  carpi  ulnaris, 


Flexor  sublimis  digitorum 
Ulnar  nerve 


Flexor  sublimis  digitorum. 


Volar  nerve 

Palmaris  brevis 

Abductor  minimi  digiti 
Flexor  minimi  digiti, 
Opponens  minimi  digiti, 

Lumbricales  2d,  3d,  4th..-' 


S ■  Flexor  carpi  radialis. 

J 

S- Flexor  profundus  digitorum. 


Flexor  sublimis  digitorum. 


Flexor  longUB  pollicis.J 

Median  nerve. 


Abductor  pollicis. 


-Opponens  pollicis. 
Flexor  brevis  pollicis. 
..Adductor  pollicis. 
^..  1st  Lumbricalis, 


Fig.  4. — Motor  points  of  flexor  aspect  of  forearm. 


little  finger,  ulnar  half  of  the  ring  finger,  and  the  dorsal  aspect  of  the  lit- 
tle and  ring  fingers  and  the  ulnar  half  of  the  middle  finger,  with  the  ex- 
ception of  the  first  phalanx,  which  is  supplied  by  the  median  nerve. 

Paralysis  of  this  nerve,  therefore,  leads  to  partial  loss  of  the  power  of 
flexion  of  the  wrist  and  fingers.  The  paralysis  of  the  interossei  causes 
loss  of  power  of  adduction  and  abduction  of  the  fingers,  and  also  of  flex- 


PERIPHERAL    PARALYSIS.  287 

ion  of  the  first  phalanx  and  extension  of  tlie  second  and  third  phalanges. 
When  the  paralysis  is  complete  and  long-continued,  a  very  peculiar  and 
characteristic  deformity  is  produced,  on  account  of  the  unopposed  action 
of  the  antagonists  of  the  interossei,  viz.,  the  superficial  and  deep  flexors, 
which  flex  the  second  and  third  phalanges,  and  the  common  extensor, 
which  extends  the  first  phalanx.  The  contraction  of  the  latter  muscle 
causes  hyperextension  of  the  first  phalanges;  the  action  of  the  former 
produces  complete  flexion  of  the  second  and  third  phalanges,  thus  giving 
rise  to  what  is  known  as  the  "  claw-hand." 

In  addition,  paralysis  of  the  adductor  pollicis  causes  diminution  in 
the  power  with  which  the  thumb  can  be  pressed  against  the  index  finger; 
paralysis  of  the  muscles  of  the  hypothenar  eminence  interferes  with  the 
various  movements  of  the  little  finger.  In  severe  forms  of  paralysis,  the 
muscles  undergo  atrophy,  and  this  is  very  readily  detected  when  the  dor- 
sal interossei  are  affected;  the  metacarpal  bones  then  project  prominent- 
ly and  depressions  are  visible  between  them. 

There  may  be  considerable  loss  of  muscular  power  without  any  affec- 
tion of  sensation  ;  when  present,  the  latter  usually  affects  the  integu- 
ment in  the  manner  referred  to  in  describing  the  distribution  of  the 
nerve,  but  variations  are  also  observed  in  the  case  of  this  nerve,  though 
not  so  marked  as  in  paralysis  of  the  median.  The  only  variation  which 
has  come  under  my  own  notice  has  been  that  the  loss  of  sensation  has 
extended  over  the  outer  half  of  the  flexor  aspect  of  the  ring  finger,  and 
has  affected  half  instead  of  a  third  of  the  palm. 

When  the  paralysis  is  due  to  an  irritative  lesion  of  the  nerve,  it  is 
not  infrequently  complicated  with  numbness  and  tingling,  or  lancinating- 
pains  in  the  anaesthetic  regions.  The  trophic  and  vaso-motor  disturb- 
ances which  are  noticeable  are  similar  to  those  occurring  in  other  par- 
alyses of  the  arm. 

Etiology. 

This  form  of  paralysis  is  due  in  the  majority  of  cases  to  traumatic 
influences,  to  which  the  nerve  is  often  subjected  on  account  of  its  ex- 
posed position.  These  include  blows  upon  the  forearm,  sleeping  on  the 
arm,  wounds  with  a  knife  or  other  sharp  instrument,  pressure  of  a  straight- 
jacket,  pressure  of  a  crutch  upon  the  nerve  in  the  axilla.  It  is  also  pro- 
duced by  neuritis  due  to  exposure  or  to  the  propagation  of  inflammation 
from  surrounding  parts,  and  to  the  pressure  of  a  neuroma  or  other  form 
of  tumor. 

The  peculiar  claw-shaped  hand  is  not  pathognomonic  of  this  form  of 
paralysis,  but  is  also  observed  at  times  in  progressive  muscular  atrophy. 
But  other  characteristic  symptoms  then  serve  to  differentiate  the  two 
affections.  Thus,  in  the  latter  the  atrophy  often  begins  in  the  muscles 
of  the  ball  of  the  thumb,  it  gradually  spreads  up  the  arm,  and  then 
travels  to  the  trunk  and  lower  limbs,  involving  the  muscles  irrespective 
of  their  nervous  supply,  sensory  disturbances  are  entirely  absent  and  the 
loss  of  power  keeps  pace^:>«r4^jass<6  with  the  muscular  atrophy. 

Treatment. 

The  treatment  of  ulnar  paralysis  is  similar  to  that  of  the  other  nerves 
of  the  arm.  Electricity  is  employed  in  this  affection  by  applying  one 
electrode    upon   the  fold    of  the  elbow  over  the  inner  condyle,  and  the 


238  FUNCTIONAL    NERVOUS    DISEASES. 

other  upon  the  inner  side  of  the  wrist  (Fig.  3).  The  interossei  are 
electrized  by  placing  one  electrode  over  the  nerve  at  the  wrist  and  the 
other  over  the  motor  points  of  the  muscles  as  shown  in  Fig.  4,  or  by 
placing  one  electrode  in  the  palm  in  the  manner  described  on  page  335, 
in  speaking  of  electrization  of  the  lumbricales. 

When  there  is  a  tendency  to  the  development  of  the  "  claw-hand," 
the  contracture  of  the  muscles  should  be  overcome  by  the  application  of 
a  straight  splint  to  the  palm  of  the  hand  and  fingers.  Galvanization  of 
the  opposing  muscles  is  also  said  to  be  useful  under  these  circum- 
stances. Too  much  must  not,  however,  be  expected  from  the  employ- 
ment of  these  measures,  as  the  peculiar  deformity  may  develop  despite  all 
treatment,  and  render  the  hand  entirely  useless. 


Paralysis  of  the  Musculo-spiral  Nerve. 
Clinical  History. 

During  its  course  through  the  spiral  groove  of  the  humerus,  this 
nerve  is  distributed  to  the  triceps,  anconeus,  supinator  longus,  and  exten- 
sor carpi  ra.dialis  longior  ;  it  also  supplies  the  integument  of  the  outer 
and  posterior  aspect  of  the  lower  half  of  the  arm,  and  the  upper  two- 
thirds  of  the  posterior  aspect  of  the  forearm.  The  nerve  divides  into 
the  radial  and  posterior  interosseous  nerves,  the  former  being  distributed 
to  the  integument  of  the  outer  half  of  the  dorsum  of  the  hand  and  the 
dorsal  aspect  of  the  thumb,  the  index  finger  and  outer  half  of  the  mid- 
dle finger,  with  the  exception  of  the  third  phalanges  (which  are  supplied 
by  the  median).  The  posterior  interosseous  nerve  is  distributed  to  all 
the  muscles  on  the  posterior  aspect  of  the  forearm. 

This  form  of  paralysis  of  the  nerves  of  the  arm  is  much  more  com- 
mon than  the  varieties  previously  described,  and  also  differs  from  the 
other  varieties  in  the  fact  that  it  very  often  occurs  separately,  though 
the  branch  above  the  elbow  is  rarely  involved  except  in  combination  with 
other  nerves  of  the  brachial  plexus. 

The  branches  supplying  the  triceps  and  the  integument  of  the  arm  are 
so  rarely  involved  apart  from  paralysis  of  the  other  nerves  of  the  plexus, 
that  it  is  unnecessary  to  consider  them  in  this  connection. 

Paralysis  of  the  extensors  gives  rise  to  the  characteristic  appearance 
known  as  wrist-drop,  the  hand  and  first  phalanges  being  flexed,  the 
second  and  third  jDhalanges  extended.  The  patients  are  unable  to  extend 
the  wrist  voluntarily,  and  for  this  reason  the  flexors  of  the  forearm  are 
also  apparently  weakened  (vide  page  182).  When  the  paralysis  is  com- 
plete and  affects  both  arms,  the  patients  are  rendered  almost  entirely 
helpless,  as  the  loss  of  power  of  the  extensors  not  only  prevents  the  per- 
formance of  extension,  but  the  inability  to  steady  the  wrist  also  interferes 
with  flexion  of  the  fingers.  Paralysis  of  the  supinator  longus  causes 
partial  loss  of  the  power  of  supination  of  the  forearm  (this  is  partially  ef- 
fected by  the  biceps)  and  also,  to  a  certain  extent  of  flexion,  as  this  func- 
tion is  assumed  by  the  supinator  when  the  forearm  is  maintained  in  a 
semipronated  position.  A  very  characteristic  appearance  is  presented 
when  the  paralysis  is  attended  with  muscular  atrophy;  the  prominence 
upon  the  outer  side  of  the  forearm,  produced  by  the  bellies  of  the  exten- 
sor muscles  is  lost,  and  in  extreme  cases  the  finger  may  be  pressed  deep 
into  the  posterior  interosseous  space. 


PERIPHERAL    PARALYSIS.  239 

In  lead  paralysis,  as  we  have  previously  pointed  out,  the  supinator 
longus  is  only  exceptionally  affected,  and  we  therefore  find  that  tliis  mus- 
cle stands  out  prominently,  while  the  other  extensors  may  be  wasted  to 
such  an  extent  that  they  are  detected  with  difficulty. 

This  form  of  paralysis  has  appeared  to  me  to  he  more  frequently  com- 
plicated with  trophic  disturbances  than  the  other  paralyses  of  the  nerves 
of  the  arm. 

Its  etiology  embraces  the  entire  list  of  causes  which  have  been  de- 
scribed as  productive  of  ulnar  and  median  paralysis.  In  addition,  lead 
palsy  is  usually  localized  in  the  distribution  of  this  nerve.  The  majority 
of  cases  of  musculo-spiral  paralysis,  however,  are  due  to  sleeping  upon 
the  arm,  allowing  it  to  hang  over  the  edge  of  a  chair,  etc.  Among  up- 
ward of  twenty-five  of  my  cases  due  to  the  latter  cause,  in  all  but  two 
the  paralysis  developed  while  the  patients  were  sleeping  off  the  effects  of 
a  heavy  debauch.  It  occurs  with  so  much  greater  frequency  under  these 
conditions,  because  the  patients  sleep  more  heavily  and  change  their  posi- 
tion less  frequently.  Gowers  '  reports  two  cases  in  which  paralysis  of  the 
musculo-spiral  nerve  occurred  from  violent  contraction  of  the  triceps 
muscle. 

Diagnosis. 

The  diagnosis  ef  this  form  of  paralysis  is  readily  made  from  the  posi- 
tion of  the  hand  and  the  inability  to  perform  extension.  It  is  often  diffi- 
cult, however,  to  determine  whether  the  paralysis  is  due  to  lead  poison- 
ing or  to  other  causes.  In  the  former  event,  there  is  usually  a  history  of 
the  entrance  of  lead  into  the  system  in  some  manner,  the  patient  has  suf- 
fered from  one  or  more  attacks  of  lead  colic,  a  blue  line  is  present  upon 
the  gums,  and  the  supinator  longus  is  unaffected  in  the  large  majority  of 
cases.  In  addition,  the  paralysis  generally  involves  both  arms,  and,  in 
fact,  any  bilateral  paralysis  of  the  extensors,  in  which  a  cause  cannot  be 
determined,  should  lead  us  to  suspect  the  presence  of  lead  in  the  system. 

In  one  case  under  my  observation  bilateral  paralysis  of  the  extensors 
was  due  to  rheumatic  influences,  viz.:  exposure  to  a  high  wind.  The 
patient,  a  washerwoman,  hung  clothes  upon  the  roof  in  a  strong  wind,  her 
arms  being  wet  at  the  time,  and  upon  the  following  morning  awoke  with 
wrist-drop  in  both  arms.  The  disease  was  differentiated  from  lead-palsy 
by  the  fact  that  there  was  no  history  of  lead-poisoning,  no  blue  line  on 
the  gums,  the  supinators  were  affected  to  the  same  extent  as  the  exten- 
sors, and  the  paralysis  ensued  shortly  after  the  action  of  a  sufficient  ex- 
citing cause. 

In  rare  cases  some  difficulty  is  experienced  in  differentiating  the  dis- 
ease from  progressive  muscular  atrophy,  but  the  latter  is  generally  accom- 
panied by  atrophy  of  muscles  in  other  parts  of  the  upper  limbs,  especially 
in  the  interossei  and  muscles  of  the  ball  of  the  thumb. 


Treatment. 

The  treatment  is,  in  general  terms,  the  same  as  that  of  ulnar  and  me- 
dian paralysis.  The  extensor  muscles  are  electrized  by  placing  one  elec- 
trode over  their  general  origin  from  the  external  condyle  of  the  humerus 

'  Medical  Times  and  Gazette,  1877,  p.  475. 


240  FUNCTIONAL    NERVOUS    DISEASES. 

and  gently  stroking  the  posterior  surface  of  the  forearm  with  the  other; 
in  this  manner  all  the  muscles  are  successively  brought  into  play,  and 
this  method  may  be  employed  for  both  currents.  (Figs.  5  and  6.)  Gal- 
vanization of  the  nerve  may  be  effected  by  placing  one  electrode  in  the 
fold  of  the  elbow  over  the  external  condyle  and  the  other  at  the  back 
of  the  wrist  in  the  median  line.  In  the  treatment  of  lead-palsy  recovery 
is  sometimes  obtained  under  the  use  of  the  faradic  current,  although 
the  muscles  no  longer  respond  to  this  form  of  electricity.  In  all  cases 
of  lead-paralysis,  however,  it  is  more  advisable  to  use  the  interrupted 
galvanic  current. 

When  wrist-drop  develops,  the  extensor  muscles,  as  we  have  previously 
Been,  are  put  upon  the  stretch,  and  this  condition  interferes,  to  a  certain 
extent,  with  the  progress  of  recovery.  Various  devices  have  been  re- 
sorted to  in  order  to  obviate  this  difficulty,  the  simplest  being  that  in- 
vented by  Dr.  Van  Bibber,  and  which  may  be  modified  in  various  ways. 


External  head  of  triceps 


Musculo-spiral  nerve., 
Brachialis  anticns. . . . 


/ 


Supinator  longus 

Extensor  carpi  radialis  longior.. 


Extensor  carpi  radialis  brevier. / 


/ 


Fig.  5. — Motor  points  of  outer  aspect  of  arm. 


A  fingerless  glove  is  worn  upon  the  paralyzed  hand,  into  the  back  of  which 
is  inserted  a  wire  loop  in  the  median  line.  Another  loop  is  inserted  over 
the  posterior  surface  of  the  elbow  by  means  of  a  piece  of  moleskin  plas- 
ter, which  adheres  to  the  back  of  the  arm;  an  artificial  muscle,  consisting 
of  simple  rubber  tubing,  is  then  introduced  between  the  two  wire  loops, 
and  should  be  drawn  sufficiently  tight  to  keep  the  hand  continually  in 
slight  extension.  A  rubber  ring  or  band  of  any  description  may  be 
placed  around  the  wrist  (allowing  the  artificial  muscle  to  pass  between  it 
and  the  skin),  thus  preventing  the  apparatus  from  rubbing  against  the 
clothes  and  becoming  displaced.  When  the  apparatus  has  been  properly 
adjusted  the  patient  is  often  enabled  to  perform  movements  with  the 
hand  which  were  previously  impossible,  and  the  relief  of  the  muscular 
tension  undoubtedly  facilitates  recovery. 


PERIPHERAL    PARALYSIS. 


241 


Whenever  this  form  of  paralysis  (as  well  as  all  the  other  varieties  of 
paralysis  of  the  nerves  of  the  arm)  is  attended  with  trophic  changes  in  the 
joints  (pain,  swelling  of  the  ends  of  the  bones,  ankylosis),  considerable 
benefit  is  often  derived  from  the  persistent  use  of  hot  douches,  applied 
half  an  hour  daily,     lu  severe  cases  the  constant  galvanic  current  may  be 


Supinator  longns 

Extensor  carpi  radialis  longior.. . . 


Extensor  carpi  radialis  brevior. 
Extensor  communis  digitorum.. 


1st  dorsal  interosseous.u 

2d  dorsal  interrosseous 

3d  dorsal  interrosseous ' 


i-SM Extensor  carpi  ulcarig. 

I      :iXi'|f|^L Extensor  minimi  digiti. 

m      ^l^'K^^         Extensors  of  the  thumb. 

1 Extensor  indicis. 

Abductor  minimi  digriti. 
4th  dorsal  interosseous. 


Fig.  6. — Motor  points  of  extensor  aspect  of  forearm. 


employed,  the  current  being  passed  directly  through  the  affected  joint, 
and  a  sufficient  number  of  cells  being  used  to  cause  considerable  pain  and 
decided  redness  of  the  integument.  The  applications  should  be  made 
daily,  the  duration  varying  from  ten  to  fifteen  minutes. 

In  lead-paralysis  constitutional  treatment  is  also  required,  but  this  has 
been  referred  to  with  sufficient  detail  on  page  194. 


Combined  Paralysis  of  the  Nerves  of  the  Arm. 

With  the  exception  of  paralysis  of  the  circumflex  and  musculo-spiral 
nerves,  which  often  occur  separately,  several  of  the  nerves  of  the  brachial 
plexus  are  usually  affected  at  the  same  time.     This  is  due  to  the  fact  that 
16 


242  FUNCTIONAL    NERVOUS    DISEASES. 

the  nerves  are  situated  so  closely  together  in  their  passage  down  the 
neck  and  arm,  and  also  to  the  tendency — more  marked  in  this  than  in  any 
other  part  of  the  body — of  the  spread  of  neuritis  along  the  course  of  the 
nerve-trunks,  thus  leading  to  the  secondary  implication  of  other  branches 
of  the  plexus.  As  we  have  shown  in  the  course  of  our  general  remarks 
on  peripheral  paralysis,  neuritis  descendens  as  well  as  ascendens  are  ob- 
served in  the  nerves  of  the  upper  limbs,  and  in  some  cases,  indeed,  the 
inflammatory  process  extends  to  the  spinal  cord. 

Erb  first  described  a  peculiar  form  of  paralysis  in  which  the  deltoid, 
biceps,  brachialis  anticus  and  supinator  longus  were  paralyzed,  and,  at 
times,  the  muscles  supplied  by  the  median  nerve  in  the  forearm.  Erb 
believed  that  this  form  of  paralysis  was  due  to  a  lesion  situated  at  the 
exit  of  the  sixth  cervical  nerve  from  the  scalenus  muscle,  as  the  application 
of  the  faradic  current  to  this  spot  will  produce  contraction  of  the  above- 
mentioned  muscles.  These  observations  have  been  since  confirmed  by 
Ernst  Remak  ^  and  H.  ten  Gate  Hoedemaker.*  As  Erb  has  pointed  out, 
the  same  group  of  muscles  are  sometimes  affected  in  the  paralysis  of  the 
upper  arm  occurring  during  parturition,  which  was  first  described  by 
Duchenne.  This  combination  does  not,  however,  always  occur  under 
such  circumstances;  a  case  of  this  kind  has  been  reported  by  Bailly  and 
Onimus,  and  another  has  come  under  my  observation,  the  following  being 
a  short  abstract  of  the  history: 

Case  IX. — Julius  H.,  set.  3  months,  in  robust  health;  the  head  was 
delivered  by  forceps,  and  the  shoulders  were  then  found  to  be  tightly 
wedged  in  the  pelvis,  so  that  the  accoucheur  had  great  difficulty  in  dis- 
engaging them,  and  exerted  considerable  force  in  this  manipulation. 
Immediately  after  delivery  it  was  noticed  that  the  left  arm  hung  limp  by 
the  side,  and  the  only  movement  observed  in  the  limb  was  the  power  of 
flexion  of  the  fingers.  The  measurements  of  the  arms  are  exactly  the 
same,  and  the  child  is  so  plump  that  it  is  impossible  to  tell  whether  the 
muscles  are  atrophied.  When  the  arm  is  raised  to  the  horizontal  it  drops 
down  perfectly  limp;  irritation  of  the  limb  gives  rise  to  no  movements 
except  flexion  of  the  fingers.  Examination  shows  that  there  is  no  frac- 
ture or  dislocation  of  the  humerus.  None  of  the  muscles,  with  the  ex- 
ception of  the  flexors  of  the  fingers,  react  to  the  faradic  current,  and  only 
slight  contractions  are  observed  on  the  application  of  the  interrupted 
galvanic  current;  sensation  appears  to  be  normal. 

In  comparatively  rare  cases  the  entire  limb  is  paralyzed  as  the  result 
of  a  lesion  to  the  peripheral  nerves,  usually  from  tumors  growing  from 
the  brachial  plexus,  from  the  pressure  of  the  dislocated  head  of  the  hu- 
merus, or  from  direct  injury  received  during  falls,  etc.  When  the  paraly- 
sis of  the  arm  is  complete,  the  prognosis  is  very  gloomy,  and  complete 
recovery  rarely,  if  ever,  occurs. 

Two  cases  of  paralysis  of  the  entire  plexus  are  under  my  observation 
at  present,  one  of  which  is  due  to  a  fall  upon  the  shoulder,  the  exciting 
cause  of  the  other  being  unknown.  In  the  former,  the  circumflex  and 
musculo-spinal  nerves  are  chiefly  affected  (the  degeneration-reaction  is 
present  in  the  corresponding  muscles),  in  the  latter  the  median  and  ulnar 
nerves  are  most  seriously  implicated. 

'  Berl.  klin.  Wschrft.  No.  9,  1877.  ^  Arch.  f.  Psych.  IX.  p.  738. 


CHAPTER  XII. 

PARALYSIS  OF  THE  NERVES  OF  THE  LOWER  LIMBS. 

Paealtsis  of  the  Obturator  Nerve. 

Clinical  History. 

This  nerve  supplies  the  adductors  of  the  thigh,  the  obturator  muscles, 
and  the  gracilis  and  pectineus  ;  it  is  also  distributed  to  the  integument 
of  the  inner  aspect  of  the  thigh  in  its  lower  two-thirds.  This  form  of 
paralysis  is  extremely  rare  and  its  symptoms  are  not  very  marked  ;  they 
consist  merely  of  loss  of  the  power  of  adduction  of  the  thigh  (adductors, 
gracilis,  pectineus)  and  to  a  certain  extent  of  external  rotation  (obturators). 
The  paralysis  may  develop  either  on  one  or  both  sides,  and  occurs  more 
frequently  in  combination  with  crural  paralysis  than  separately.  The 
loss  of  power  is  rarely  very  great  and  does  not  cause  the  patient  very 
much  inconvenience. 

Etiology. 

This  form  of  paralysis  may  occur  as  the  result  of  tumor  growths  upon 
the  Cauda  equina,  wounds  of  the  lower  portion  of  the  spinal  cord,  psoas 
abscesses,  pressure  upon  the  nerve  during  forceps  delivery  or  by  a  large 
fcetal  head,  wounds  of  the  nerve  after  its  exit  from  the  pelvis.  In  one 
unique  case,  the  notes  of  which  were  furnished  me  by  Dr.  V.  P.  Gibney, 
the  paralysis  was  apparently  due  to  over-exertion  of  the  muscles,  the  re- 
sult of  excessive  coitus. 

Case  X. — "  Minnie  M.,  set,  19  years,  a  prostitute.  Two  years  ago,  the 
patient,  according  to  her  own  account,  had  a  vaginal  abscess  on  the  left 
side.  Last  July  another  abscess  developed  in  the  same  locality,  and  this 
was  opened.  Upon  attempting  to  get  out  of  bed  she  found  herself  una- 
ble to  walk  and  suffered  from  pains  in  the  lower  limbs  ;  there  were  no 
cincture  pains  or  d  sturbance  of  the  functions  of  the  bladder.  Two 
months  elapsed  before  she  began  to  go  about,  and  she  then  could  only 
walk  very  slowly  ;  she  has  been  gradually  getting  better.  She  now 
walks  pretty  well  on  a  level,  but  gets  upstairs  with  great  diflSculty  ;  she 
is  unable  to  adduct  the  thighs  and  carry  one  across  the  other. 

"  November  29th.  The  vagina  was  examined  quite  carefully  (though 
the  light  was  not  good)  but  no  cicatrix  of  an  abscess  could  be  found  ;  ilie 
uterus  appears  to  be  in  the  normal  position  ;  no  evidences  of  specific  dis- 
ease. 

"  The  adductors  of  the  thigh  are  found  to  be  very  feeble,  especially  in 
the  right  limb  ;  these  muscles  are  also  very  flabb}'' ;  there  is  also  some 
paresis  of  the  extensors  of  the  thigh.  The  faradic  excitability  is  dimin- 
ished in  the  adductor  group  of  the  right  limb.     The  patient  suffers  from 


244 


FUNCTIONAL    NERVOUS    DISEASES. 


pain  at  the  knee  and  inner  aspect  of  the  thigh  {distribution  of  the  obtu- 
rator). 

"  December  15th.  The  patient  has  been  receiving  faradism  to  the 
affected  muscles  three  times  a  week  and  thinks  she  can  walk  much  bet- 
ter.    February  15th  reports  herself  entirely  well. 

"  Upon  inquiry  it  was  found  that  the  patient  had  had  coitus,  for  the 
past  two  years,  about  seven  or  eight  times  a  week,  and  that  she  had  been 


Crural  nerve _.., i_     ''T 

Obturator  nerve /S|y 

Sartorius ■ 

Adductor  longus _.,.  _ 

Branch  of  crural  nerve  to  com.  exteu- „ 

sor.  l/f  S 

Crureus _  \. 

|— ^ 

Vastus  intemus _         <;         ^ 

\'' 

\ 

\ 
I 
f 


.  Rectus  f  emoris. 


^^ 


.  Vastus  extemus. 


Fig.  7. 


, — Motor  points  of  anterior  region  of  thigh. 


very  much  addicted  to  performing  intercourse  in  "  fancy  positions."  As 
the  affected  muscles  were  the  ones  which  would  be  chiefly  strained  in  such 
manoeuvres,  it  is  reasonable  to  conclude  that  the  disease  was  brought 
about  in  this  manner." 

Treatment. 

The  treatment  consists  simply  in  the  application  of  electricity,  one 
electrode  being  applied  to  the  inner  side  of  the  thigh,  a  little  below  Pou- 
part's  ligament,  in  the  position  indicated  on  Fig.  7,  and  the  other  being 
moved  to  and  fro  over  the  adductor  group  near  their  insertion  into  the 
femur. 


Paralysis  of  the  Anterior  Crural  Nerve. 
Clinical  History. 


This  nerve  supplies  the  iliacus,  quadriceps  femoris,  sartorius,  and  pec- 
tineus  muscles.  The  sensory  filaments  are  distributed  to  the  inner  half  of 
the  anterior  surface  of  the  thigh,  and  the  inner  aspect  of  the  leg  and  foot. 
Paralysis  of  this  nerve,  though  rare,  occurs  with  greater  frequency  than 


PERIPHERAL    PARALYSIS.  245 

that  of  the  obturator,  but  is  sometimes  combined  with  the  latter.  Its 
etiology  is  entirely  similar,  in  all  respects,  to  that  of  obturator  paralysis, 
though  it  is  more  frequently  caused  by  traumatism,  on  account  of  the 
more  exposed  position  of  the  nerve. 

Paralysis  of  the  anterior  crural  gives  rise  to  serious  disturbances,  es- 
pecially when  both  nerves  are  affected.  Paralysis  of  the  iliaci  causes 
partial  loss  of  the  power  of  maintaining  the  erect  position,  as  these  mus- 
cles produce  fixation  of  the  pelvis  upon  the  femur;  it  also  interferes  with 
flexion  of  the  thigh  upon  the  trunk;  the  latter  effect  is  still  further  in- 
creased by  paralysis  of  the  sartorius,  which  is  also  a  flexor  of  the  thigh. 
Paralysis  of  the  quadriceps  extensor  femoris  interferes  very  decidedly 
with  the  power  of  walking,  elevating  the  foot,  etc.;  this  muscle,  taking 
its  origin  from  the  femur  and  the  anterior  inferior  spinous  process  of  the 
ilium,  extends  the  leg  upon  the  thigh  and  thus  takes  an  active  part  in  the 
act  of  walking.  The  affected  muscles  are  usually  markedly  atrophied, 
and  this  is  readily  determined  when  compared  with  the  healthy  limb.  If 
the  patient  is  very  obese,  careful  measurements  of  the  thighs  may  become 
necessary  in  order  to  detect  the  presence  of  the  muscular  atrophy.  The 
sensory  disturbances  are  usually  of  a  slight  grade,  and  consist  of  numb- 
ness and  tingling  in  the  cutaneous  distribution  of  the  nerve. 

The  diagnosis  is  readily  made  by  inspection  of  the  parts  and  by  direct- 
ing the  patient  to  extend  the  leg  upon  the  thigh.  In  rare  cases  acute 
infantile  paralysis  is  localized  in  the  distribution  of  this  nerve,  and  the 
differentiation  of  this  affection  from  peripheral  paralysis  may  require  some 
care.  In  the  former  disease  the  paralysis  often  begins  with  constitutional 
disturbance,  the  loss  of  power  is  more  general  in  the  beginning  than  it  is 
after  the  lapse  of  a  few  days,  the  muscular  atrophy  occurs  very  rapidly, 
and  no  sensory  disturbances  are  observed. 

Treatmext. 

The  treatment,  as  in  paralysis  of  the  obturator  nerve,  consists  merely 
of  electrization,  one  electrode  being  placed  over  the  middle  of  the  base 
of  Scarpa's  triangle  and  the  other  one  passed  to  and  fro  over  the  anterior 
muscles  of  the  thigh;  the  muscles  can  be  stimulated  separately  by  placing 
the  latter  electrode  in  the  positions  shown  on  Fig.  7. 


Paralysis  of  the  Sciatic  Nerve. 
Clinical  History. 

The  sciatic  nerve  supplies  the  integument  of  the  entire  leg  and  foot, 
■with  the  exception  of  the  internal  portion  which  is  supplied  by  the  inter- 
nal saphenous.  Before  its  division  into  the  internal  and  external  poplit- 
eal, it  sends  branches  to  the  biceps,  semi-tendinosus,  semi-merabranosus 
(flexors  of  the  leg),  and  to  the  adductor  magnus.  The  internal  popliteal 
is  distributed  to  the  gastrocnemius,  soleus,  popliteus,  and  plantaris,  tibi- 
alis posticus,  flexor  longus  digitorum,  flexor  longus  pollicis,  and  the  small 
muscles  of  the  sole  of  the  foot.  The  external  popliteal  or  peroneal  nerve 
is  distributed  to  the  tibialis  anticus,  extensor  longus  digitorum,  extensor 
proprius  pollicis,  the  peronei,  and  extensor  brevis  digitorum. 

Paralysis  of  this  nerve  is  much  more  frequent  than  that  of  the  other 


246  FUNCTIONAL    NERVOUS    DISEASES. 

nerves  of  the  lower  limb,  on  account  of  its  great  length  and  more  exposed 
situation.  It  is  comparatively  infrequent,  hov^ever,  when  compared  with 
paralysis  of  the  nerves  of  the  upper  limb.  It  may  be  due  to  hemorrhages 
within  the  spinal  canal,  to  the  pressure  of  tumors  upon  the  cauda  equina, 
to  fracture  of  the  lower  lumbar  vertebrge  (in  one  case  under  my  observa- 
tion both  sciatics  were  completely  paralyzed  in  consequence  of  fracture 
of  the  second  lumbar  vertebrae  with  forward  dislocation) ;  it  may  also  be 
caused  by  the  pressure  of  intra-pelvic  tumors,  of  the  forceps  or  a  large  head 
during  a  severe  and  protracted  delivery.  After  the  exit  of  the  nerve 
from  the  pelvis,  traumatism  plays  a  prominent  part  in  the  production  of 
peripheral  paralysis,  and  the  nerve  is  usually  involved  after  its  bifurcation 
into  the  internal  and  external  popliteal,  the  latter  being  most  frequently 
affected.  The  injury  may  consist  of  a  bullet  or  knife  wound,  blow  with 
a  club,  a  fall  upon  the  buttocks,  the  pressure  of  a  strait-jacket  or,  as  in 
one  interesting  case  which  I  observed,  kneeling  upon  a  ridged  tin  roof, 
which  caused  paralysis  of  the  muscles  supplied  by  the  anterior  tibial 
nerve;  paralysis  of  the  nerve  after  its  exit  from  the  pelvis  may  also  be 
due  to  rheumatic  influences  (exposure  to  wet  or  cold).  In  rare  cases,  lead 
palsy  or  paralysis  after  acute  infectious  diseases  may  involve  the  muscles 
supplied  by  the  sciatic,  the  former  being  restricted  almost  exclusively  to 
the  distribution  of  the  anterior  tibial  nerve  (extensors  of  the  foot).  Fi- 
nally, a  few  cases  have  been  reported  in  which  paralysis  occurred  in  the 
distribution  of  the  sciatic  nerve  as  the  result  of  version  by  the  foot  during 
transverse  presentation.  I  once  saw  a  case  of  this  kind  in  consultation,  in 
which  the  paralysis  was  bilateral,  and  in  which  the  accoucheur  confessed 
tliat  he  had  used  great  violence  during  version.  In  this  case,  however, 
the  other  nerves  of  the  lower  limbs  were  also  paralyzed,  and  it  seemed  to 
me  probable  that  the  lesion  consisted  of  a  hemorrhage  around  the  cauda 
equina. 

Paralysis  of  the  branches  distributed  to  the  biceps,  semi-membranosus 
and  semi-tendinosus,  causes  loss  of  the  power  of  flexion  of  the  leg  upon 
the  thigh.  When  the  biceps  contracts  alone,  it  produces  slight  rotation 
of  the  leg  outward;  contraction  of  the  semi-membranosus  causes  slight 
rotation  inward.  These  movements  are  also  lost  in  paralysis  of  the  nerve 
above  its  bifurcation. 

Paralysis  of  the  internal  popliteal  gives  rise  to  well-marked  symp- 
toms. Paralysis  of  the  gastrocnemius,  soleus,  and  plantaris  causes  loss 
of  the  power  of  raising  the  heel  from  the  floor  in  walking,  and  therefore 
interferes  very  materially  with  locomotion.  In  severe  forms  contracture 
of  the  opposing  extensor  muscles  of  the  foot  develops,  and  gives  rise  to 
the  production  of  talipes  calcaneus.  After  this  condition  has  continued 
for  a  long  time,  changes  occur  in  the  joint  surfaces,  but  the  consideration 
of  these  symptoms  belongs  to  the  orthopedic  surgeon.  Paralysis  of  the 
tibialis  posticus  interferes  with  extension  of  the  tarsus  upon  the  leg, 
inversion  of  the  sole  of  the  foot,  and  adduction  of  the  foot.  This  gives 
rise  to  the  production  of  calcaneo-valgus.  Paralysis  of  the  flexor  longus 
digitorum  and  flexor  longus  pollicis  causes  loss  of  the  power  of  flexion 
of  the  second  and  third  phalanges.  When  the  small  muscles  of  the  sole  of 
the  foot  are  paralyzed,  their  function  is  undoubtedly  lost,  but  we  possess 
such  little  voluntary  power  over  the  individual  muscles,  and  the  latter  are 
so  much  engaged  in  the  performance  of  reflex  acts,  that  it  is  difficult  and 
in  many  cases  impossible  to  differentiate  the  action  of  one  from  the  other. 
The  muscles  supplied  by  the  internal  popliteal  are  almost  invariably  par- 
alyzed together. 


PERIPHERAL    PARALYSIS. 


24^ 


Paralysis  of  the  external  popliteal  is  much  more  frequent  than  that 
of  the  internal  popliteal  or  of  the  trunk  of  the  nerve,  as  it  is  more  exposed 
on  account  of  its  position  in  the  anterior  portion  of  the  leg.  Paralysis 
of  the  tibialis  anticus  interferes  with  flexion  of  the  foot  and  with  adduc- 
tion to  a  certain  extent,  and  also  allows  the  antero-posterior  arch  of  the 
foot  to  sink.  When  contracture  of  the  antagonists  occurs,  therefore, 
pes  equinus  is  produced.  Paralysis  of  the  extensor  longus  digitorum, 
extensor  pollicis  proprius  and  peroneus  tertius  also  interferes  witVi  flexion 
of  the  foot,  and  at  the  same  time,  with  abduction;  contracture  of  the 
antagonists  therefore  leads  to  pes  equino-varus.  The  peronei  longus  and 
brevis  are  extensors  of  the  foot  upon  the  leg,  acting  in  combination  with 


Gluteus  maxiimis 

Sciatic  nerve 

Biceps  (long  head) 

Biceps  (short  bead) 


„|  "■■s/3l:~i;'®fflS  ,— Adductor  magnua. 

■•     •vTj^^—- — Semitendinosus. 

"Semimembranosus. 


Tibial  nerve 

Peroneal  ner\'e 

External  head  of  gastrocnemius.. 

Soleus _ 


— Internal  head  of  gastrocnemius. 


Fig.  8. — Motor  points  of  posterior  region  of  thigh. 


the  tibialis  posticus  in  this  respect.  The  peroneus  longus  also  abducts 
the  foot,  and,  at  the  same  time,  everts  it.  In  addition,  this  muscle,  as 
Duchenne  has  shown,  holds  the  transverse  arch  of  the  sole  of  the  foot  in 
place  by  pressing  the  base  of  the  first  metatarsal  bone  against  the  adja- 
cent bones.  Its  paralysis  therefore  gives  rise  to  a  certain  degree  of  flat 
foot,  which  becomes  complete  if  the  tibialis  anticus  is  also  paralyzed. 


Diagnosis. 

In  these  cases,  also,  it  is  often  difficult  to  differentiate  peripheral 
paralysis  from  infantile  paralysis  limited  usually  to  the  group  of  muscles 
supplied  by  the  external  popliteal  nerve.  It  must  be  remembered  that 
the  analogous  disease  may  also  occur  occasionally  in  the  adult,  and  a  case 


248 


FUNCTIONAL    NERVOUS    DISEASES. 


of  this  kind  has  come  under  my  notice  in  which  it  was  difficult  to  exclude 
the  peripheral  character  of  the  affection.  The  differential  symptoms  have 
been  so  often  mentioned,  that  it  is  unnecessary  to  refer  to  them  again. 

If  the  entire  nerve  is  paralyzed,  and  especially  if  the  other  nerves  of 
the  limb  are  implicated,  we  should  make  a  careful  examination  of  the 
pelvic  viscera  and  also  of  the  spinal  column,  in  order  to  determine 
whether  the  paralj'sis  may  not  be  due  to  an  affection  of  these  organs. 

We  should  also  be  on  our  guard  against  mistaking  contracture  of  the 
muscles  for  paralysis,  as  such  an  error  may  be  fraught  with  serious  con- 


Peroneus  longus- 

Tibialis  anticus 


Extensor  longus  digitorum — 


Extensor  brevis  digitorum- 


Dorsal  interossel 


Peroneal  nerve. 

External    head    of    gastroc- 
nemius. 

?1^:  -a.....Soleus. 

■— Exten-or    communis    digito- 
rum longus. 


_.Peronens  brevia. 


g Soleus. 


Plexor  longos  digitorum. 


^  — Extensor    communis    digito- 
rum brevis. 


■Abductor  minimi  digiti. 


Fig.  9.— Motor  points  of  outer  side  of  leg. 


sequences  in  regard  to  treatment.  A  mistake  of  this  nature  can  only  be 
obviated  by  a  careful  examination  of  the  affected  parts,  by  observing 
which  muscles  are  atrophied,  and  especially  by  noting  the  mobility  of 
the  parts.  When  the  joints  are  very  tender,  it  may  become  necessary  to 
place  the  patient  under  ether  in  order  to  make  a  careful  examination. 


Treatment. 

When  the  paralysis  has  been  of  longstanding,  and  is  complicated  with 
contracture  qf  unparalyzed  muscles  and  with  the  various  forms  of  talipes. 


PERIPHERAL    PARALYSIS.  210 

the  treatment  belongs  properly  in  tlie  hands  of  the  orthopaedic  surgeon. 
The  medical  treatment  consists  entirely  of  the  application  of  electricity, 
the  current  being  varied  according  to  the  rules  so  often  laid  down.  One 
electrode  should  be  placed  over  the  nerve,  the  other  passed  along  the 
muscles.  In  the  thigh,  the  nerve  is  readily  found  below  the  gluteal  fold 
a  little  to  the  outside  of  the  median  line  of  the  limb  (Fig.  8);  in  the  leg 
the  external  peroneal  is  found  to  the  outside  of  the  popliteal  space, 
whence  it  winds  over  the  head  of  the  tibula;  the  internal  popliteal  is  a 
little  to  the  inside  of  the  former  (Fig.  9).  The  motor  points  of  the  muscles 
are  very  well  shown  upon  these  figures  and  need  no  further  explanation. 
In  paralysis  of  the  anterior  group  of  muscles,  considerable  improve- 
ment in  the  power  of  walking  maybe  obtained  immediately  by  the  appli- 
cation of  an  artificial  muscle,  in  the  manner  employed  by  Dr.  Sayre  in  the 
treatment  of  club-foot. 


INDEX. 


INDEX. 


Accommodation,  paralysis  of,  198 

Actual  cautery,  116 

Acute  neuritis,  1G9 

Agraphia,  45 

Alveolar  neuralgia,  124 

Angel-wing  deformity,  236 

Anterior  crural  nerve,  paralysis  of,  244 

clinical  history,  244 

treatment,  245 
Arm,  combined  paralysis  of  nerves  of,  241 
Arsenic  paralysis,  184 
Athetosis,  14 

case  of,  14 

lesions  of,  16 
Aura,  psychical,  45 

sensory,  45 

motor,  46 

vaso-motor,  46 

Bladder,  chorea  of,  6 

case  of,  6 
Brachial  neuralgia,  136 

cUnical  history,  136 

etiology,  139 

diagnosis  and  prognosis,  140 

treatment,  140 
Brodie's  joint,  158 
Bromide  of  potassium,  87 
Bromism,  87 

Carcinoma  op  the  vertebrae,  145 
Caries  of  the  vertebrae,  144 
Causalgia,  136 
Cerebral  ansemia,  109 
Cerebro-spinal  sclerosis,  35 
Cervical  caries,  134 
Chorda  tympani,  course  of,  203 
Chorea.  1 

clinical  history,  1 

etiology,  IS 

pathological  anatomy,  24 


Chorea — pathology,  30 

diagnosis  and  prognosis,  35 

treatment,  38 

condition  of  pupils  in,  7 

electrical  reactions  in,  5 

embolismic  theory  of,  32 

thrombotic  theory  of,  33 

experiments  on  production  of,  30 

heart-murmurs  in,  6 

insanity  in,  8 

sensation  in,  7 

spinal  tenderness  in,  7 

gravidarum,  11 

nutans,  1 

syphilitic,  22 
Chronic  cervical  pachymeningitis,  139 
Chronic  neuritis,  170 
Ciliary  neuralgia,  123 
Circumflex  nerve,  i^aralysis  of,  231 

clinical  history,  231 

etiology,  231 

diagnosis,  232 

treatment,  233 
Clarus  hystericus,  126 
Claw-hand,  237 
Compression  of  nerves,  166 
Congenital  chorea,  18 
Convulsive  centre,  75 
Cooper's  irritable  breast,  142 
Counter-irritation,  by  electricity,  116 
Crural  neuralgia,  147 

Degeneration-reaction,  168 
Diet  of  epileptics,  86 
Diphtheritic  paralysis,  177 
Diplegia  facialis,  211 
Diplopia,  196 

Eclampsia  infantum,  79 
Electrical  reactions  in  peripheral  paralysis, 
168 


254 


IKDEX. 


Epilepsia  gravior,  43 
Epilepsy,  43 

clinical  history,  43 

etiology,  61 

pathological  anatomy,  73 

diagnosis  and  prognosis,  77 

treatment,  83 

death  in,  81 

examination  of  urine  in,  51 

experimental  pioduction  of,  75 

nervous  discharges  in,  76 

sphygmographic  tracings  in,  48 

spasm  of  the  glottis  in,  48 

petechial  eruption  in,  48 
Epileptic  coma,  49 

cry,  47 

insanity,  59 
EpUeptic  paroxysms,  apparent  volition  in, 

56 
Epileptic  physiognomy,  58 
Epileptics,  marriage  of,  85 
Epileptiform  neuralgia,  1 23 
Epileptic  vertigo,  54 
Epileptogenic  zone,  67 
Epileptoid  states,  56 
Erysipelas  in  neuralgia,  94 
£tat  de  mal  epileptique,  51 

Faciax,  paralysis,  206 

clinical  history,  206 

etiology,  211 

diagnosis  and  prognosis,  213 

treatment,  214 

sense  of  smell  in,  208 

sense  of  taste  in,  208 

sense  of  hearing  in,  208 
Feigned  epilepsy,  77 

Galvanism  in  neuralgia,  117 
Glossy  skin,  137 
Glycosuria  in  sciatica,  154 
Grand  mal,  43 

Hair,  trophic  changes  of,  95 
Headache  of  Bright' s  disease,  127 
Hemichorea,  3 
Hemicrania,  126 
Heredity,  01 

in  neuralgia,  97 
Herpes  ophthalmicus,  123 

zoster,  95 
Hypoglossus,  paralysis  of,  223 

clinical  history,  223 


Hypoglossus — diagnosis,  224 

treatment,  224 
Hysterical  convulsions,  80 

joints,  158 

Ilio-inguinal  neuralgia,  147 
Injuries  of  nerves,  165 
Insanity,  epileptic,  59 
Intercostal  neuralgia,  142 

clinical  history,  142 

etiology,  143 

diagnosis,  144 

treatment,  145 
Irradiated  neuralgia,  93 
Irregidar  epilepsy,  54 
Ischsemic  paralysis,  184 

Joint  changes  in  brachial  neuralgia,  138 

Kidneys,  cirrhosis  of,  79 
Kleptomania,  56 

Larvated  epilepsy,  54 

Laryngeal  chorea,  2 

Lead  paralysis,  180 

Ligature  of  the  carotid  in  neuralgia,  120 

Locomotor  ataxia,  pains  of,  110 

Lumbar  neuralgia,  147 

cliuical  history,  147 

etiology,  149 

diagnosis,  149 

treatment,  150 

Malarial  chorea,  22 
Mammary  neuralgia,  142 
Masturbation  ra  epilepsy,  65 
Median  nerve,  paralysis  of,  234 

clinical  history,  234 

etiology,  235 

treatment,  235 
MeduUa  oblongata,  lesions  of,  in  epilepsy, 

74 
Melancholia  in  neuralgia,  96 
Menopause  neurosis,  100 
Mercurial  paralysis,  184 
Migraine,  126 
Morbus  coxae,  158 

Motor  oculi  communis,  paralysis  of,  197 
Multiple  neuritis,  170 
Multiple  sclerosis,  35 
Muscular  rheumatism,  108 
Musculocutaneous  nerve,  paralysis  of,  233 

clinical  history,  233 


INDEX. 


255 


Musculo- spiral  nerve,  paralysis  of,  238 

clinical  liialory,  288 

diagnosis,  239 

treatment,  239 
Myalgia,  108 

Nails,  trophic  changes  of,  in  neuralgia, 

95 
Nerves,  compression  of,  1G6 

injuries  of,  165 
Nerve-stretching,  120 
Nervous  discharge,  76 
Neuralgia,  91 

clinical  history,  91 

etiology,  97 

pathology,  105 

diagnosis  and  prognosis,  108 

treatment,  112 

Anstie's  theory  of,  105 

Uspensky's  theory  of,  106 

Benedikt's  theory  of,  107 

motor  complications,  93 

vaso-motor  complications,  94 

secretory  complications,  94 

trophic  complications,  94 

periodicity  of,  91 
Neurectomy,  120 
Neuritis,  acute,  169 

chronic,  170 

ascendens,  174 

multiple,  170 
Neurotomy,  120 

Obturator  nerve,  paralysis  of,  243 

clinical  history,  243 

etiology,  243 

treatment,  244 
Occipital  neuralgia,  132 

clinical  history,  132 

etiology,  133 

diagnosis  and  prognosis,  134 

treatment,  134 
Ocular  muscles,  paralysis  of,  196 

general  remarks,  196 

etiology,  199 

diagnosis  and  prognosis,  200 

treatment,  201 
Orchiepididymitis,  neuralgia  in,  104 
Osteocopic  pains,  109 
Oxyokoia,  208 

Painful  points,  92 

Pains  of  locomotor  ataxia,  110 


Paralysis  agitans,  36 

after  arsenical  poisoning,  184 

after  mercurial  poisoning,  184 

df rigor  e,  176 

definition  of,  1G3 

diphtheritic,  177 

following  infectious  diseases,  177 

following  typhoid  fever,  179 

ischasmic,  184 

in  children,  diagnosis  of,  187 

in  chorea,  3 

lead,  180 

of  the  fourth  nerve,  199 

of  the  nerve  of  mastication,  203 

of  the  ocular  muscles,  19G 

of  the  sixth  nerve,  199 

of  the  third  nerve,  197 

reflex,  174 

rheumatic,  176 

syphilitic,  186 

toxic,  180 
Paresis,  definition  of,  163 
Patheticus,  paralysis  of,  199 
Periodicity  of  neuroses,  92 
Petit  mal,  52 
Perineuritis,  171 
Peripheral  paralysis,  163 

clinical  history,  163 

diagnosis  and  prognosis,  187 

treatment,  192 
Physiognomy,  epileptic,  58 
Points  apophysaires,  92 
Pott's  disease,  144 
Post-hemiplegic  chorea,  13 

lesions  of,  13 
Pregnancy,  chorea  of,  11 
Pre-hemiplegic  chorea,  13 
Prodomata,  epileptic,  44 

remote,  44 

immediate,  45 
Prophylaxis  of  neuralgia,  113 
Prosopalgia,  122 
Psychical  degeneration,  epileptic,  59 

disturbances,  transitory,  in  epileppy, 
59 
Psychoses,  epileptic,  60 
Ptosis,  197 
Puncta  dolorosa,  92 

theory  of,  107 
Phrenic  nerve,  paralysis  of,  230 

clinical  history,  230 

treatment,  230 


256 


INDEX, 


Reflex  epilepsy,  66 

neuralgia,  103 

paralysis,  174 
Rheumatic  paralysis,  176 
Rheumatism  and  chorea,  20 

Sciatica,  151 

clinical  history,  151 

etiology,  154 

diagnosis  and  prognosis,  157 

treatment,  159 
Sciatic  nerve,  paralysis  of,  245 

clinical  history,  245 

diagnosis,  247 

treatment,  248 
Serratus  magnus,  paralysis  of,  225 

clinical  history,  225 

etiology,  227 

diagnosis  and  prognosis,  236 

treatment,  229 
Skin,  atrophj^  of,  94 

hypertrophy  of,  94 
Skull,  malformation  of,  in  epilepsy,  73 
Sleep-states,  57 
Spinal  accessory,  paralysis  of,  218 

clinical  history,  218 

etiology,  220 

diagnosis  and  prognosis,  220 

treatment,  221 
Spinal  hemiplegia,  peripheral,  188 

irritation,  109 
Spinous  points,  92 


Spondylitis  deformans,  133 
Status  epilepticus,  51 

convulsive  stage,  51 

meningitic  stage,  52 

temperature  in,  52 
Sweating,  epUeptic,  57 
Sympathetic  system  in  epilepsy,  lesions  of, 

74 
Syphilitic  epilepsy,  71 
Syphilitic  paralysis,  186 

Tic  douloureux,  122 
Toxic  paralysis,  180 
Trachelismus,  47 
Trephining,  83 
Trigeminal  neuralgia,  122 

clinical  history,  122 

etiology,  124 

diagnosis  and  prognosis,  126 

treatment,  127 
Trochlearis,  paralysis  of,  199 

Ulnar  nerve,  paralysis  of,  236 
clinical  history,  236 
etiology,  237 
treatment,  237 

Vertebra,  caries  of,  144 

carcinoma  of,  145 
Vertigo,  epileptic,  54 

in  ocular  paralysis,  197 


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HERMANN,  L.  Elements  of  Human  Physiology. 
Translatect  from  tho  Sixth  German  edition  by 
Arthur  Gamgee,  M.D.    8vo.  $6  40 

*HEUSTIS,J.W.     Medical  Topography  and  Dis- 
eases of  Louisiana.    8vo.  50 
HEWITT,  G.    Diagnosis  and  Treatment  of  the 
Diseases  of  Women.    Third  edition.    8vo.    Cloth, 
4  00;  sheep,                                                              5  00 
HEWITT,  G.    The  Mechanical  System  of  Uterine 
Pathology,  being  the  Harveian  Lectures  delivered 
before  the  Harveian  Society  of  London,  December 
isrr.    4to.                                                        3  00 
♦HEW^SON,  A.      Earth  as  a  Topical  Application 
in  Surgery.    Photographs.    12mo.                      2  50 
HEWSON,   W.      The  Works  of,   on  the  Blood, 
Glands,  etc.,  etc.     Notes,  etc.,  by  G.  Gulliver, 
M.D.    Plates.    Svo.                                                 3  00 
HICKMAN,  W.    On  some  Varieties  and  Effects  of 
Cancerous  Diseases  of  Bone.    Svo.                      1  40 
HICKS,  J.  B.    On  Combined  External  and  Inter- 
nal Version.    Svo.                                                   1  40 
HIGGEN3,  C.    Hints  on  Ophthalmic  Out-patient 
Practice.    Second  edition.    llJmo.                       1  00 
HIGGINBOTTOM,   J.    A  Practical  Treatise  on 
the  Use  of  Nitrate  of  Silver  in  the  Treatment  of 
Inflammation,  Wounds,  and  Ulcers.  Third  edition. 
Svo.                                                                            2  40 
HILL,   B.    The  Essentials  of  Bandaging;  includ- 
ing the  IManagement  of  Fractures  and  Disloca- 
tions.   Fourth  edition,  revised.    16mo.              2  00 
HILL,  B.    Syphilis  and  Local  Contagious  Disor- 
ders.   Svo.                                                                3  25 
HILL,    B.,  and    A.    COOPER.      The    Student's 
Manual  of  Venereal  Diseases:   being  a  Concise 
Deseri^jtion  of  those  Affections  and  their  Treat- 
ment.   ISmo.                                                           1  00 
HILL,  G.    Limacy,  its  Past  and  Present.  Svo.  1  40 
HILL,  J.  D.    An  Analysis  of  140  Cases  of  Organic 
Strictm'e  of  the  Urethra.    Svo.                             120 
HILLES,  M.  W.    The  Essentials  of  Physiology. 
Fourth  edition,  improved  and  illustrated  with  141 
wood  engravings.    IGmo.                                      4  20 
HILLES,  M.  W.    The  Anatomist.    Being  a  Com- 
plete Description  of  the  Anatomy  of  the  Human 
Body.    32mo.                                                           1  00 
HILLES,  M.  W.    Regional  Anatomy;  or,  a  Guide 
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HILLIER,  T.    Hand-book  of  Skin  Diseases,  for 
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HILLIER,  T.    Diseases  of  Children  Treated  Clin- 
icaUy.    Svo.                                                             2  00 
HILTON,  J.    OnRest  and  Pain:  A  Course  of  Lec- 
tures oil  the  Influence  of  Mechanical  and  Physio- 
logical Rest  in  the  Treatment  of  Accidents  and 
Surgical  Diseases.    Edited  by  W.  H.  A.  Jackson. 
Second  Edition.    16mo.                                         3  60 
HINTON,  J.    Thoughts  on  Health  and  some  of  its 
Conditions.    12mo.                                                 2  40 
HINTON,  J.    Physiology  for  Practical  Use.  12mo. 

2  25 

HINTON,   J.     The  Questions  of  Aural  Surgery. 

Illustrated.    12mo.  5  00 

HINTON,  J.    An  Atlas  of  Diseases  of  the  Mem- 

brana  Tympani.  One  hundred  and  fifty  Drawings 

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50  00 
HINTON,  J.    The  Place  of  the  Physician.    The 
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HIPPOCRATES.  The  Genuine  Works  of.  Trans- 
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*HOBBS,  C.  E.  Botanical  Hand  book  of  Com- 
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most  of  the  Crude  Vegetables,  tougs,  etc.,  in  com- 
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HOBLYN,  R.  D.  A  Dictionary  of  Terms  used  in 
Medicine  and  tlie  Collateral  Sciences.  Additions 
by  I.  Hays,  M.D.  12mo    Cloth,  §1  50;  sheep,  §2  03 

*HODGE,  H.  L.  Note  Book  for  Cases  of  Ovarian 
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*HODGE,  H.  L.  Diseases  Peculiar  to  Woman. 
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*HODGE,  H.L.  Principles  and  Practice  of  Ob- 
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*HODGE,  H.  L.  Foeticide,  or  Criminal  Abortion. 
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HODGES,  R.  The  Nature,  Pathology,  and  Treat- 
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HODGSON,  D.  The  Prostate  Gland  and  its  En- 
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*HOFF,  O.  On  Hematuria  as  a  Symptom  of 
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73 

♦HOFFMAN,  F.  Manual  of  Chemical  Analysis, 
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*HOFFMAN,  K.  B.,  and  R.  ULTZMAN. 
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HOGG,  J.  Impairment  of  Vision  from  Spinal  Con- 
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HOGG,  J.  Skin  Diseases  ;  an  Inquiry  into  their 
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HOGG,  J.  Cataract  and  its  Treatment,  Medical 
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HOGG,  J.  The  Microscope:  its  History,  Construc- 
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HOGG,  J.  The  Domestic  Medical  and  Surgical 
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*HOLBROOK,  M.  L.  Parturition  without  Pain; 
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*H OLDEN,  E.  The  Sphygmograph  :  its  Physio- 
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HOLDEN,  L.  A  Manual  of  Dissection  of  the 
Human  Body.  Notes  and  additions  by  E.  Mason, 
M.D.    Illustrated.    Svo.  5  00 

HOLDEN,  L.,  and  LANGTON,  J.  Manual  of 
the  Dissection  of  the  Human  Body.  Illusti-ated 
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tion.   Svo.  5  50 

HOLDEN,  L.  Human  Osteology.  Comprising  a 
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HOLDEN,  L.  Landmarks,  Medical  and  Surgical. 
Second  edition.    12mo.  88 

HOLLAND,  Sir  H.  Medical  Notes  and  Reflec- 
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HOLLAND,  Sir  H.  Recollections  of  a  Past  Life. 
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HOLMES,  G.  Physiology  and  Hygiene  of  the 
Voice,  with  Especial  Reference  to  its  Cultivation 
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Singers.    Illustrated.    12ino.  2  00 

*HOLMES,  O.  W.  Currents  and  Counter  Cur- 
rents in  Medical  Science,  and  other  Addresses,  etc. 
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WILLIAM  WOOD  &  CO:S  MEDICAL  CATALOGUE. 


21 


HOLMES,  T.  A  System  of  SurRery,  Tlieoretical 
and  Practical,  in  Treatises  by  Various  Authors. 
Secontl  edition.  5  vols.  8vo.  Cloth,  $40  00  ;  half 
morocco,  S^-*  W 

HOLMES,  T.  Surgery:  its  Principles  and  Prac- 
tice.   Svo.    Cloth,  SO  00;  sheep,  7  00 

HOLMES,  T.  The  Surgical  Treatment  of  the 
Diseases  of  Infancy  and  Childhood.  Illustrated. 
Second  edition.    Svo.  8  00 

HOLT,  B.  On  the  Immediate  Treatment  of  Stric- 
ture, bv  the  Employment  of  the  "  Stricture  Dila- 
tor."   Third  edition.    8vo.  ~ -10 

HOLTHOUSE,  C.  On  Hernial  and  other  Tumors 
of  the  Groin  autl  Neigliborhood.    8vo.  3  GO 

*HOMO  versus  DARWIN.  A  Judicial  Examina- 
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win, regarding  "The  Descent  of  Man."  12mo.  1  00 

HOOD,  P.  The  Successful  Treatment  of  Scarlet 
Fever,  etc.    l:2mo.  3  00 

HOOD,  P.  A  Treatise  on  Gout,  Rheumatism,  and 
the  Allied  AtTections.    Second  edition.    8vo.    3  50 

HOOD,  W.  P.  On  Bone-Setting  (so-called),  and 
its  relation  to  the  Treatment  of  Joints  crippled  by 
Injur}-,  Iniiammation,  etc.    ICmo.  1  75 

HOOPER'S  Physician's  Yade  Mecum.  Ninth  edi- 
tion. Kevised  by  Drs.  Guy  and  Harley.   lOnio.  5  00 

HOOPER,  R.  Lexicon  Medicum :  or,  Medical 
Dictionary.    Additions  by  S.  Akerley,  M.D.    Svo. 

3  00 

HOPE,  G.  H.  Till  the  Doctor  Comes,  and  How  to 
Help  Him.    limo.  60 

HOPE,  J.    Principles  of  Pathological  Anatomy. 
Edited  by  L.  M.  Lawson,  M.D.    2(30  colored  illus- 
trations.   Svo.  12  00 
*HOPKIN3    ITOSPITAL   PLANS.     Five  Essaj-s 
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*HOPPE,  C.    Percussion  and  Auscultation  as  Di- 
agnostic Aids.    Ti-anslated  by  L.  C.  Lane,  M.D. 
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*HORNER,W.  E.    The  United  States  Dissector; 
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H.Smith;  M.D.    Illustrated.    12mo.  2  00 
*HORNER,  'W.    E.     Special  Anatomy  and  His- 
tology.   Illustrated.    2  vols.  Svo.  6  00 
HORSLEY,  J.    The  Toxicologist's  Guide  ;  a  New 
Manual  of  Poisons.    ICimo.  1  50 
HORTON,  J.   A.    B.     The  Diseases  of  Tropical 
Climates  and  their  Treatment:  with  Hints  for  the 
Preservation  of  Health  in  the  Tropics.     Second 
edition.    lOmo.  5  00 
HOVELL.  D.  De  S.    Medicine  and  Psychology  ; 
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HOVELL,  D.  DeS.    On  Pain  and  other  Symptoms 
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80 
HOWE,  A.  H.    A  Theoretical  Enquiry  into  the 
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"HOWE,  A.  J.    A  Practical  and  Systematic  Trea- 
tise on  Fractures  and  Dislocations.    Illustrated. 
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♦HO'WE,  A.J.    The  Ai-t  and  Science  of  Surgery. 
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*HOWE,  J.  W^.    "Winter  Climate  for  Invalids.    An 
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HUDSON,  A.    Lectures  on  the  Study  of  Fever. 

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HUFELAND'S  Art  of  Prolonging  Life.  Edited 
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HUGHES,  J.  S.  Diseases  of  the  Prostate  Gland. 
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HUGMAN,  W.  C.  On  Hip-Joint  Disease,  with 
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HULL,  E.  C.  P.  The  European  in  India,  with  a 
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HUMPHREY,  G.  M.  On  the  Human  Skeleton 
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HUMPHREY,  G.  M.  The  Human  Foot  and  the 
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HUMPHREY,  G.  M.    The  Hunterian  Oration,  de- 
livered at  the  Roval  College  of  Surgeons  of  Eng- 
land, on  the  14th'of  February,  1S79.    Svo.  1  00 
*HUNT,  D.   Some  General  Ideas  Concerning  Medij 
cal  Reform.    Small  4to.  75 
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ture and  Treatment.    Seventh  edition.     Greatly 
enlarged,  and  entirely  revised.    IJmo.               2  00 
HUNT,  T.    The  Diseases  of  the  Skin;  a  Guide  to 
tlieu-  Treatment  and  Prevention.    IGmo.           1  00 
HUNTER,  C.    Blechanical  Dentistry  :  a  Practical 
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HUNTER,  C.  Y.    Body  and  Mind,  the  Nervous 
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Drugs  for  the  Medicine  Chest,  vnth  plain  direc- 
tions for  their  use.    lOmo.                                     2  40 
HUNTER,  J.    The  Natural  History' and  Diseases 
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T.  Bell,  F.R.S.    Plates.    Svo.                                1  00' 
HUNTER,  J.    The  "Works  of,  with  Notes  by  J.  F- 
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HUNTER,  J.    The  Anatomy  of  the  Human  Gravid 
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*HUNTER,   J.   B.    A  Manual  of  Gynaecological 

Operations.    Illustrated.    Svo. 
HUSBAND,  H.  A.    The  Student's  Handbook  of 
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HUSBAND,  H.  A.    The  Student's  Handbook  of 
Forensic  Bledicine  and  Medical  Police.    Third  edi- 
tion.    lOmo.  4  20 
HUSBAND,    H.   A.      Examination  Questions   in 
Anatomy,  Physiology,   Botan.y,  Materia  JMedica, 
Surgery,  etc.    New  edition.    32mo.  1  40 
HUTH,  A.  H.    The  Marriage  of  Near  Kin  Con- 
sidered with  Respect  to  the  Laws  of  Nations,  Re- 
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Svo.  5  60 
HUTCHINSON, J.    AClinical  Memoir  on  Certain 
Diseases  of  the  E.ye  and  Ear,  consequent  on  In- 
herited Syphilis.    Svo. 
HUTCHINSON,  J.    Lectures  on  Clinical  Surgery. 
Vol.  I.,  on  Certain  Rare  Diseases  of  the  Skin.   Svo. 

4  20 

HUTCHINSON,  J.  Illustrations  of  Clinical  Sur- 
gery ;  consisting  of  Colored  Plates  and  Photo- 
graphs, "Woodcuts,  Diagrams,  etc.  Illustrating 
Surgical  Diseases,  SjTnptoms,  Accidents,  etc. 
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*HO'WE,  J.  "W.  Emergencies,  and  how  to  Treat 
them.  Tlie  etiology.  Pathology,  and  Treatment 
of  the  Accidents,  Diseases,  and  (I'ases  of  Poisoning, 
which  demand  prompt  attention.    Svo.  2  50 


♦HUTCHINSON,  J.  H.    The  Inflammatory  Origin 
of  Phthisis.    Svo.  25 

HUXLEY,  T.  H.    A  Manual  of  the  Anatomy  of 
Vertebrated  Animals.    12mo.  2  50 


23 


WILLIAM  WOOD  &  CO:S  MEDICAL  CATALOGUE. 


HUXLEY,  T.  H.  A  Manual  of  the  Anatomy  of 
Invertebrated  Animals.    l;:imo.  S^  50 

HUXLEY,  T.H.  An  Introduction  to  the  Classifi- 
cation  of  Animals.    Illustrated.    8vo.  2  40 

HUXLEY,  T.  H.  Lessons  in  Elementary  Physi- 
ology.   New  edition.     IGmo.  1  50 

HUXLEY,  T.  H.,  and  H.  N.  MARTIN.  A  Course 
of  Practical  Instruction  in  Elementary  Biology. 
Third  edition.    12mo.  2  00 

*  H  Y  D  E ,  F .  E .  Warm  and  Hot  Water  in  Surgery. 
A  Short  Historical  Sketch,  with  the  present  most 
Approved  Methods  of  Application,  with  Cases. 
6vo.  50 

MRAY,    K.      Popular    Cyclopaedia    of 

Modem  Domestic  Medicine.      Colored 

Plates.    8vo.  5  00 

I  INFLUENZA  ;  or.  Epidemic  Catarrhal 

Fever,  Annals  of,  in  Great  Britain,  from 

1510  to  1837.    Edited  by  T.  Thompson,  M.D.    8vo. 

3  00 
INMAN,  T.    On  the  Restoration  of  Health:  Being 
Essays  on  the  Principles  upon  which  the  Treat- 
ment of  many  Diseases  is  to  be  conducted.    Second 
edition.     13mo.  3  00 

INMAN,  T.  The  Preservation  of  Health;  or.  Es- 
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by  those  who  Desire  to  Avoid  Disease.  Third 
edition.    12mo.  2  CO 

IRELAND,  W.  W.  On  Idiocy  and  Imbecility. 
8vo.  5  60 

*IZARD,  A.  A.  New  Treatment  of  "Venereal  Dis- 
eases and  Ulcerative  Syphilitic  Affections  by  Iodo- 
form. Translated  by  H.  F.  Damon,  M.D.  16mo. 
paper.  50 

ACOBI,  A.  Acute  Rheumatism  in  In- 
fancy and  Childhood.  8vo.  25 
*JACOBI,  A.  Infant  Diet.  Revised, 
Enlarged,  and  Adapted  to  Popular 
Use  by  Mary  Putnam-Jacobi,  M.D. 
Boards,  50c.    Cloth.                                                   75 

*JACOBI,  MARY  P.  The  Question  of  Rest  for 
Women  during  Menstruation.    Illustrated.    8vo. 

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JACKSON,  J.  H.  Clinical  and  Physiological  Re- 
searches on  the  Nervous  System.  No.  1.  On  the 
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JACKSON,  J.  H.  Remarks  on  the  Routine  Use  of 
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JAEGER,  E.  Test  Types,  for  the  Determination 
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JAGO,  J.  Ocular  Spectres  and  Structm-es  asMutual 
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JAGO,  J.  Entoptics,  with  its  Uses  in  Physiology 
and  Jledicine.    Plates.    12mo.  2  00 

JAMES,  J.  H.  On  the  Distinctive  Characters  of 
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JAMES,  J.  H.  Chloroform  versus  Pain,  and  Para- 
centesis of  the  Bladder  above  the  Pubes.  8vo.  1  00 

JAMES,  J.  H.  Observations  on  the  Operations  for 
Strangulated  Hernia.    8vo.  2  00 

JAMES,  M.  P.  Sore  Throat,  its  Nature,  Varieties, 
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Fourtli  edition.     Colored  plates.     16mo.  2  00 

JAMES,  P.  Lessons  in  Laryngoscopy  and  Rhino- 
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•JANEWAY,  E.  G.  Points  in  the  Diagnosis  of 
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•JEFFERIES,  B.  J.  Diseases  of  the  Skin;  the 
Recent  Ad%ances  in  their  Pathology  and  Treat- 
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•JEFFERIES,  E.  J.  The  Eye  in  Health  and  Dis- 
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*JEFFERIES,  B.  J.  Color  Blindness,  its  Dan- 
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ERFFI,  G.  G.  Spiritualism  and  Animal 
Magnetism.  A  Treatise  on  Dreams, 
Second  Sight,  Somnambulism,  etc. 
lUmo.  60 

ZIEMSSEN'S  Motor  Points  of  the  Hu- 
man Body,  a  Map  of.  (A  Guide  to  Localized. 
Electrization.)  Withi30  wood  Engravings.  Mounted 
on  roller  and  varnished.  2  50 

♦ZIEMSSEN'S  CYCLOPAEDIA  OF  THE 
PRACTICE  OF  MEDICINE.  17  vols,  and 
Index.  Per  Vol.  cloth,  $5  00;  sheep,  SO  00;  half 
morocco,  $7  50;  half  Russia,  $8  50.  By  Subscrip- 
tion only. 


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ZIEMSSEN'S  CYCLOPAEDIA  of  the 

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STANDARD  MEDICAL  AUTHORS. 

Published  in  Monthly  Volumes.     Bound. 


BUCK'S  TREATISE   ON  HYGIENE 

AND   PUBLIC  HEALTH.     2  Volumes. 


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Folio.     38  Superb  Colored  Plates  with  Text.     Bound. 


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On  Medicine  and  Collateral  Sciences. 

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HE  MICEOSCOPE  AND  MICROSCOPICAL  TECHNOLOGY  :  A 
Text-Book  for  Physicians  and  Students.  By  Prof.  Heinrich  Frey. 
Translated  and  Edited  by  G.  R.  Cutter,  M.D.,  Surgeon  to  the  New 
York  Eye  and  Ear  Infirmary,  Ophthalmic  and  Aural  Surgeon  to  the 
St.  Catharine  and  Williamsburg  Hospitals,  etc.  Illusti-ated  by  338  engravings 
on  wood.  Second  edition.  In  one  handsome  8vo  volume.  Cloth,  $6.00; 
colored  leather,  $7.00. 

NOTICES  OF  THE  PRESS  OF  THE  FHIST  EDITION. 


"  Those  who  are  familiar  with  Frey  's  admira- 
ble manual  will  feel  grateful  to  Dr.  Cutter  for 
liis  very  readable  translation,  which  enables 
our  American  aud  German  students,  who  are 
unacquainted  with  the  English  tongue,  to  par- 
ticipate in  the  instructions  of  the  renewed 
Zurich  professor.  These  directions  for  inves- 
tigation possess  an  especial  value  to  the  Ameri- 
can olDserver,  on  account  of  the  explicit  man- 
ner in  which  are  described  the  manifold  im- 
proved methods  of  demonstrating  the  various 
structures  in  their  healthy  or  diseased  con- 
ditions. To  sum  up  all,  we  think  that  this 
handsome  volume  is  one  which  the  working 
microscopist  cannot  afford  to  do  without." — 
Philadelphia  Medical  Times. 

"  We  advise  all  commencing  the  study  of 
microscopj^  to  purchase  Frey  on  the  Micro- 
scope."—Buffalo  Med.  and  Surg.  Journal. 

"  It  is  a  pleasure,  indeed,  to  call  the  atten- 
tion of  the  profession  to  this  very  superior 
work.  With  this  excellent  work  the  beginner 
and  the  expert  i:)Ossess  all  that  can  be  desired 
for  the  prosecution  of  their  studies  and  inves- 
tigations."— Richmond  and  Louisville  Med. 
Jour. 

"In  many  respects  we  think  this  the  best 
work  on  the  Microscope."— Defroii  Review  of 
Medicine. 


"A  complete  exposition  of  the  subject, 
thoroughly  indispensable  to  the  practical  mi- 
croscopist."— Chicago  Medical  Journal. 

"  The  work  is  presented  very  modestly,  yet 
we  find  it  not  only  very  accurate  in  all  its  de- 
tails of  process.biit  complete  as  regards  variety 
of  topics  treated.  The  condensed  style  of  the 
author,  the  fairness  of  his  nature,  together 
with  his  understanding  of  histologfy,  permit 
an  unbiassed  discussion  of  nearly  all  questions 
of  microscopic  anatomy,  and  many  of  obsciu'e 
pathology.  The  rules  for  testing  and  select- 
ing an  instrument  are  especially  valuable  to 
one  about  to  purchase."— iV.  Y.  Jour,  of  Med. 

"  We  conceive  this  work,  of  all  others,  par- 
ticularly fitted,  by  its  completeness  ancl  ar- 
rangement, to  serve  the  stu-^ent,  whether 
beginner  or  one  far  advanced.  The  best  and 
most  recent  methods  are  here  given  in  detail. 
The  additions  of  the  editor  make  this  part  of 
the  work  complete  to  the  present  time.  Each 
tissue  and  organ  is  treated  with  a  complete- 
ness limited  only  by  the  present  progress  of 
microscopic  art.  The  translator  and  editor 
deserves  the  gratitude  of  the  medical  profes- 
sion for  placing  before  an  English  reading 
public  Dr.  Frey's  work,  rendered  still  more 
valuable  by  his  own  judicious  brackets." — 
Brown-Sequard''s  Archives  of  Scientific  and 
Practical  Medicine, 


PRACTICAL  TREATISE  ON  NERVOUS  EXHAUSTION  (NEURAS- 
THENIA), its  Symptoms,  Nature,  Sequences,  and  Treatment.  By  George 
M.  Beard,  AM.,  M.D.,  Fellow  of  the  New  York  Academy  of  Medicine  ; 
of  the  New  York  Academy  of  Sciences;  Vice-President  of  the  American 
Academy  of  Medicine;  Member  of  the  American  Neurological  Association; 
of  the  American  Medical  Association ;  the  New  York  Neurological 
Society,  etc.    In  one  handsome  8vo  volume,  bound  in  cloth,  price  $1.75. 


*'  In  this  country  r.ervons  exhaustion  (neur- 
asthenia) is  more  common  than  any  other 
form  of  nervous  disease.  With  the  various 
neuroses  with  which  it  is  allied,  and  to  which 
it  leads,  it  constitutes  a  family  of  functional 
disorders  that  are  of  comparatively  recent 
development,  and  that  abound  especially  in 
the  northern  and  eastern  part  of  the  United 
States."— JEarfracf/rom  Preface. 


Contexts.- Chapter  I..  Introduction;  Chap- 
ter II.,  Symptoms  of  Nervous  Exhaustion; 
Chapter  111.,  Nature  and  Diagnosis  of  Nervous 
Exhaustion  ;  Chapter  IV.,  Prognosis  and  Se- 
quence of  Nervous  Exhaustion  ;  Chapter  V., 
Treatment  and  Hygiene  of  Nervous  Exhaus- 
tion. 


PRACTICAL  TREATISE  ON  SURGICAL  DIAGNOSIS.  Designed 
as  a  Manual  for  Practitioners  and  Students.  By  Ambrose  L. 
Ranney,  A.m.,  M.D.  Adjunct  Professor  of  Anatomy,  and  Lec- 
turer on  Minor  Surgery  in  the  Medical  Department  of  tlie  Univer- 
sity of  New  York.  In  one  octavo  volume,  bound  in  extra  muslin.  Price, 
$3.00. 

"With  the  exception  of  Macleod's  'Out- 
lines,' published  simultaneously  in  England 
and  in  this  country,  in  1854,  this  is,  so  far  as 
we  know,  the  first  monograph  ever  issued  on 
surgical  ilia.gaosia.'"— Philadelphia  Med.  'rimes. 

"  The  chief  source  of  perplexity  in  the  prac- 
tice of  medicine  and  surgery  is  to  find  out 
what  is  the  matter  with  tlie  patient.  Uncom- 
fortable, indeed,  is  the  reflection  of  a  practi- 
tioner when  he  has  left  a  case  bandaged  and 
dressed  for  a  fracture,  when,  perchance,  it 
may  be  a  dislocation.  Dr.  Ranney  has  given 
us  a  book  to  assist  us  in  all  such  states  of  un- 
certainty, and  he  has  done  well ;  for  in  pre- 
senting the  symptoms  of  disease  in  marlced 
contrast,  it  makes  the  diagnosis  of  similar 
troubles  really  easy."— ro^edo  Med.  and  Surgi- 
cal Journal. 


"Useful  on  account  of  its  systematic  ar- 
rangement."— Cincinnati  Lancet  and  Clinic. 

"  We  are  at  a  loss  to  see  how  more  informa- 
tion could  have  been  condensed  in  fewer 
words." — Chicago  ited.  Journ.  and  Exam. 

"The  system  and  arrangement  of  the  volume 
are  highly  commendable,  and  the  author  has 
carried  them  out  well."— Su.  Practitioner. 

"  A  very  good  aid  to  surgical  diagnosis  for 
both  advanced  surgeons  and  beginners.  As  a 
text-book  for  surgical  lectures  it  is  quite  valu- 
able."—.b't.  Louis  Clin.  Record. 

"  From  the  sample  page  given,  the  value  of 
this  work  will  be  readily  seen,  we  trust,  appre- 
ciated, and  meet  with  the  hearty  reception  it 
deserves." — Toledo  Med.  and  Surg.  Journal. 


A  MANUAL  OF  PHYSICAL  DIAGNOSIS.  By  Francis  Delafield,  M.D., 
and  Charles  F.  Stillman,  M.D.  A  Manual  for  Teaching  and  Learning 
the  Art  of  Pliysical  Diagnosis.  Interleaved  for  notes.  Illustrated  with  a 
superb  lithographic,  superimposed,  transparent  plate.  In  one  handsome, 
quarto  volume,  bound  in  extra  muslin.     Price,  $3.00. 

"  The  want  of  conciseness  in  the  ordinaiy 
manuals  on  physical  diagnosis  affects  the 
average  student,  and  they  never  learn  it  until 
compelled  to.  This  work  is  an  exception  to 
this  rule. — Ohio  Medical  Recorder. 


"We  cannot  imagine  anyway  in  which  the 
practical  study  of  pliysical  diagnosis  can  be 
made  more  easy  than  by  the  aid  of  this 
superb  work." — Pacific  Medical  and  Surgical 
Journal. 


TREATISE  ON  HYGIENE  AND  PUBLIC  HEALTH.  Edited  by 
Albert  H.  Buck,  M.D.  Contributors  to  the  Work  :  D.  F.  Lincoln, 
M.D.,  of  Boston;  Prof.  Jas.  Tyson,  M.D. ,  of  Philadelphia;  A.  Bray- 
ton  Ball,  M.D.,  of  New  York;  Arthur  Van  Harlingen,  M.D.,  of 
Philadelphia;  Wm.  H.  Ford,  M.D.,  of  Philadelphia  ;  Prof.  Wm.  Ripley 
Nichols,  of  Boston;  Roger  S.  Tracy,  M.D.,  of  New  York  ;  T.  B.  Curtis, 
M.D.,  of  Boston;  Col.  J.  S.  Billings,  Surgeon  U.S.A.;  S.  O.  Vander- 
poel,  M.D.,  of  New  York;  Elwyn  Waller,  Ph.D.,  of  New  York; 
Capt.  Chas.  Smart,  Assistant  Surgeon  U.S.A.,  Fort  Preble,  Me.  ;  H.  C. 
Sheafer,  Esq.,  Pottsville,  Pa.  ;  Francis  H.  Brown,  M.D.,  Marine  Hospi- 
tal, Chelsea,  Mass.  ;  Thomas  J.  Turner,  M.D.,  Inspector  U.S.  Navy,  of 
Washington;  Prof.  Abraham  Jacobi,  M.D.,  of  New  York;  Allan  McLean 
Hamilton,  M.D.,  of  New  York  ;  S.  S.  Herrick,  of  New  Orleans ; 
and  others.  In  two  vols.  8vo,  of  about  700  pages  each,  with  numerous 
illustrations.  Price,  muslin  binding,  per  vol.,  $5.00;  leather  binding,  $6.00; 
half  morocco  binding,  $7.50. 

towards  assuring  us  that  the  work  is  one  of 
value,  and  one  that  will  Avell  repay  the  time 
occupied  in  its  study.  The  subjects  treated 
are  of  interest  not  only  to  the  phi'sieian,  who 
should  be  the  model  sanitarian,  but  also  to 
the  architect  and  builder,  to  municipal  authori- 
ties, to  teachers,  and,  in  fine,  to  all  good 
citizens  who  desire  the  highest  physical  good 
of  their  communities."  —  Toledo  Med.  and 
Surgical  Journal. 


"  We  have  in  this  work  a  creditable  monu- 
ment of  American  enterprise  and  learning,  in 
one  of  the  most  important  fields  of  study  that 
can  engage  the  attention  of  physician  and 
philanthropist. 

"  No  library,  public  or  private,  general  or 
professional,  should  for  a  day  be  without  it." 
— Si.  Louii  Courier  Medicine. 

"We  cannot  commend  these  volumes  too 
highly,  and  we  are  sure  that  no  physician  who 
purchases  and  reads  them  will  a  moment 
regi-et  the  investment." — Anierican  Practi- 
tioner, Nov.,  1879. 

"  The  entire  work  merits  the  highest  praise, 
and  it  is  to  be  hoped  that  tlie  enterprise  of  the 
publishers  will  Ije  appreciated  by  the  general 
public,  for  so  important  a  venture  in  this  im- 
portant direction  has  never  before  been  made 
m  this  coimtry,  and  is  not  likely  to  be  made 
again."— X  i'.  Ileiald. 

"  The  reputation  of  the  editor  and  a  glance 
at   the  names    of   the  contributors,  go   far 


"  Every  subscriber  to  Zipmssen  should  com- 
plete that  great  Cyclopaedia  by  obtaining  this 
work,  and  every  educated  man  should  buy 
this  first  really  comprehensive  treatise  on 
private  and  pubhc  Hygiene,  written  with 
special  reference  to  the  different  climates, 
conditions  of  soil,  habitations,  modes  of  hfe 
and  laws  of  the  United  States.  Messrs.  Wood 
&  Co.  are  entitled  to  much  credit  for  the 
admirable  dress  in  which  the  work  is  pre- 
sented. The  t>-pe  is  large  and  the  paper  ex- 
cellent, and  illustrations  have  been  freely 
introduced."— £?<^aio  Med,  and  Surg,  Jowr- 
nal. 


Medical  Works 

PUBLISHED  BY  SUBSCRIPTION 


BY 


AVM.  V/OOD   &  COMPANY. 

ZIEMSSEN'S  CYCLOPEDIA  of  the 

PRACTICE  OF  MEDICINE.     17  vols,  and  Index. 

WOOD'S  LIBRARY  OF 

STANDARD  MEDICAL  AUTHORS. 
Published  in  Monthly  Volumes.     Bound. 

BUCK'S  TREATISE  ON  HYGIENE 

AND  PUBLIC  HEALTH.    2  Volumes. 

BOCK'S  ATLAS  OF  HUMAN  ANATOMY. 

Folio.     38  Superb  Colored  Plates  with  Text.    Bound. 

MEDICAL  JOURNALS: 

The  Medical  Record,  Weekly. 

New  Remedies,  Monthly. 

American  Journal  of  Obstetrics,  Quarterly. 

THE  MEDICAL  RECORD  VISITING  LIST; 

OR,  PHYSICIANS'  DIARY  FOR  1880. 
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